Skip to main content

Full text of "A treatise on the diseases of the chest, and on mediate auscultation"

See other formats 


f\.  IJSU  ^  ^^    ^VHT 


fLATK    Z 


A    TREATISE 


DISEASES   OF  THE   CHEST, 


MEDIATE  AUSCULTATION, 


OTEC, 


By  R.  T.  H.  LAENNEC,  M.D. 

REGIUS    PROFESSOR    OF    MEDICINE    IN    THE    COLLEGE    OF    FRANCE,    CLINICAL 

PROFESSOR    TO    THE    FACULTY    OF    MEDICINE    OF    PARIS, 

&C.    &C.    &C. 

TRANSLATED  FROM  THE  THIRD  FRENCH  EDITION, 

WITH 

COPIOUS  NOTES,  A  SKETCH  OF  THE  AUTHOR'S  LIFE,  AND  AN 
EXTENSIVE  BIBLIOGRAPHY  OF  THE  DIFFERENT  DISEASES, 

By  JOHN  FORBES,  M.D.  F.R.S. 

MEMBER    OF    THE     ROYAL    COLLEGE    OF    PHYSICIANS,    PHYSICIAN     TO     THE    CHICHESTER, 

INFIRMARY,    AND    PHYSICIAN    IN    ORDINARY    TO    HIS    ROYAL    HIGHNESS 

THE    DURE    OF    CAMBRIDGE. 

TO  WHICH  ARE  ADDED  THE  NOTES 

OF 

PROFESSOR  ANDRAL, 

CONTAINED   IN    THE    FOURTH   AND    LATEST    FRENCH    EDITION,    TRANSLATE!. 

AND   ACCOMBANIED    WITH    OBSERVATIONS    ON    CEREBRAL 

AUSCULTATION, 

By  JOHN  D.  FISHER,  M.D. 

FELLOW    OF    THE    MASSACHUSETTS    MEDIC 

Uiyct  ie  fitpot  foevftxi  tsj;  tty,nfi  tticci  to  Kvarfat  *iamTi\. — HI 

NEW    YORK: 
SAMUEL  S.  AND  WILLIAM  WOOD, 

201,  Pearl  Street. 

PIULADELPHtA  : — THOMAS,   COWPERTHW  4ITE    AND    CO., 

253,  Market  Street. 


1838. 
itMWAl  vn:  ?  >■■■ 


WF 

L  isrsle. 

if  ST 


Entered,  according  to  the  Act  of  Congress,  in  the  year  one  thousand  eight  hundred  and  thirty-seven  f 
by  SAMUEL  S.  and  WILLIAM  WOOD,  in  the  Clerk's  Office  of  the  District  Court  of  the  Southern 
District  of  New  York. 


MERRIAM,   WOOD   AND   CO., — PRINTER*,, 
SPRINGFIELD,    MASS. 


A  TREATISE 


ON   THE 


DISEASES  OF  THE  CHEST, 

&c.  &c. 


** 


ADVERTISEMENT 


AMERICAN    PUBLISHERS 


The  following  work  has  already  gone  through  four 
editions  in  the  original  language.  The  fourth  edition 
which  was  published  last  year  at  Paris,  was  enriched 
with  copious  and  valuable  notes  by  G.  Andral,  M.D. 
the  distinguished  professor  in  the  Medical  School  of  that 
city. 

The  great  and  increasing  demand  which  prevails  for 
this  valuable  standard  work  has  induced  us  to  undertake 
a  new  American  edition,  with  all  the  additions  requisite 
to  give  the  book  its  most  perfect  completion.  Professor 
Andral's  notes  have  been  translated  at  our  request  by  Dr. 
J.  D.  Fisher  of  Boston,  and  we  now  offer  to  the  public 
the  great  work  of  Laennec  enriched  and  illustrated  by 
the  labors  of  his  relative,  Dr.  Meriadec  Laennec,  of  Dr. 
Forbes,  the  English  translator  of  the  original  work,  and 
of  its  latest  commentator,  Professor  Andral ;  to  which 
are  added  observations  on  Cerebral  Auscultation,  by  the 
translator  of  M.  Andral's  notes. 

The  contributions  of  Professor  Andral  render  this  edi- 
tion much  more  valuable  and  perfect  than  any  former  one: 
and  the  work,  as  now  published,  contains  an  account  of 
the  practice  of  Auscultation  in  every  form  in  which  it  has 
been  applied.  It  comprises  also,  all  that  is  known  of  the 
pathology  and  symptomatology  of  the  diseases  of  the 
thoracic  organs,  and  constitutes,  therefore,  the  most  com- 
plete Treatise  on  these  diseases  that  has  yet  been  offered 
to  the  public. 

New  York,  1838. 


JAMES   CLARK,    M.D.    F.R.S. 

E      KING     AND 


PHYSICIAN     IN     ORDINARY     TO     THEIR     MAJESTIES     THE     KING     AND     QUEEN     OF 

BELGIUM. 


to 


'X^RARi 


My  dear  friend, 

The  translation  of  the  first  edition  of  this  Treatise  was 
dedicated  to  our  eminent  friend,  the  late  Dr.  Baillie;  and 
although  there  remain  among  his  successors,  many  whose 
names  would  do  honor  to  it  in  its  present  much  improved 
form,  there  is  no  one  who  has  equal  claims  with  yourself 
to  this  address. 

Possessed  of  the  most  extensive  and  accurate  know- 
ledge of  pathology,  and  of  a  rare  sagacity  in  discrimi- 
nating the  minuter  shades  of  diseases,  you  are  in  a  more 
especial  manner  qualified  to  judge  of  the  merits  of  the 
present  work,  by  your  perfect  acquaintance  with  the  af- 
fections of  which  it  treats,  and  by  your  constant  and  suc- 
cessful practice  of  the  diagnostic  measures  recommended 
in  it.  It  was,  moreover,  in  your  valuable  Notes  on  the 
climate,  diseases,  hospitals,  and  medical  schools  of  France 
and  Italy,  that  the  transcendent  merits  of  M.  Laennec's 
work  were  first  made  known  in  this  country ;  it  was  at 
your  earnest  recommendation  and  request  that  I  under- 
took the  translation  of  it ;  it  was  by  your  precept  and 
example  that  I  was  led  to  practise  the  new  methods  of 
diagnosis  therein  detailed ;  it  is  to  you,  therefore,  in  a 
great  measure,  that  the  profession  is  indebted  for  any 
benefits,  however  slight,  that  may  have  resulted  from  my 
humble  labors. 


V11I  DEDICATION. 

But  you  have  a  claim  to  this  address,  of  more  weight 
with  me  than  your  professional  talents  and  character, 
however  distinguished,  and  the  acknowledgment  of 
which,  I  flatter  myself,  will  be  more  acceptable  to  you 
than  any  homage  I  could  offer  on  public  grounds — I  mean, 
the  friendship  with  which  you  have  favored  me  for  so 
many  years,  and  to  which  I  am  so  much  indebted. 

That  you  may  long  live  for  the  honor  and  interests  of 
our  common  profession,  and  for  the  welfare  and  happi- 
ness of  your  friends,  is  my  sincere  and  warmest  wish. 

JOHN  FORBES. 

Chichester,  Oct.  1,  1827. 


TRANSLATOR'S     PREFACtt 


TO    THE    SECOND     EDITION. 


With  all  its  imperfections  as  a  translation,  I  have  no  hesitation 
in  pronouncing  the  following  work  to  be  one  of  the  most  valuable 
that  has  ever  been  presented  to  the  medical  profession  in  this 
country.  The  original  Treatise  will  remain  an  imperishable  mon- 
ument of  the  genius  and  industry  of  the  author ;  and  the  discovery 
of  which  it  treats,  will  entitle  him  to  a  distinguished  rank  among 
the  benefactors  of  mankind.  As  a  standard  work  on  the  pathology 
and  diagnosis  of  the  diseases  of  the  chest,  it  is  not  only  without 
an  equal,  but  may  be  considered  as  almost  perfect  in  its  kind. 
Much,  no  doubt,  will  hereafter  be  discovered  that  will  modify  and 
improve  the  delineations  of  disease  which  he  has  left  us,  but  their 
great  outlines  must  remain,  unalterable  as  nature  itself. 

To  be  convinced  of  the  vast  importance  of  auscultation  as  a 
means  of  diagnosis,  it  is  only  necessary  to  peruse  the  present 
treatise  ;  and  I  can  offer  no  more  powerful  incentive  to  the  reader, 
than  to  add  my  humble  testimony  in  support  of  every  statement 
contained  in  it,  which  I  have  had  an  opportunity  of  verifying. 
Several  forms  of  disease  there  recorded,  have  not,  as  yet,  come 
under  my  observation,  and  in  some  of  the  more  common  affec- 
tions, I  have  not  hitherto  had  occasion  to  notice  every  one  of  the 
signs  described ;  but  in  no  case  have  I  met  with  any  circum- 
stance, either  of  a  positive  or  negative  kind,  which  could  give 
me  the  slightest  reason  to  doubt  any  essential  parts  of  the  au- 
thor's statements. 

At  the  same  time,  it  would  be  exacting  too  much  from  the 
weakness  of  humanity,  to  expect,  that  the  author  of  Mediate 
Auscultation  should,  in  no  case,  have  yielded  to  the  enthusiasm 
naturally  inspired  by  the  consciousness  of  so  great  a  discovery. 
And  if,  in  a  few  passages  of  his  book,  he  should  be  found  some- 
what to  exaggerate  the  actual  or  relative  importance  of  his  meth- 
od, or  even  sometimes  to  appear  rather  as  the  partisan  than  the 
historian  of  the  stethoscope,  I  am  sure  that  a  fault  so  venial,  on 
such  an  occasion,  and  in  such  a  man,  ought  not  to  be  visited  by 
heavy  censure.  Indeed,  I  am  convinced  that  every  unprejudiced 
reader,  qualified  by  the  study  and  practice  of  auscultation  to 
judge  of  the  character  of  his  work,  (and  none  else  are  qualified,) 
must  confess  that  the  author  stands  in  need  of  less  indulgence  on 
B 


X  TRANSLATOR  S    PREFACE. 

this  point  than  could  have  been  expected :   certainly  less   than 
every  candid  and  honorable  mind  will  be  ready  to  concede. 

To  estimate  fairly  the  correctness  of  M.  Laennec's  statements, 
we  ought,  also,  to  take  into  account  his  vast  experience,  and  his 
unequalled  practical  tact,  which  was  the  admiration  of  every  one 
who  had  opportunities  of  observing  his  examinations.  In  no 
case,  even  the  most  obscure,  did  he  shrink  from  pronouncing  his 
opinions,  and  fixing  his  diagnosis ;  and  rarely  indeed  was  he 
mistaken.  These  circumstances  ought  to  make  his  successors 
long  hesitate  before  they  call  in  question  the  correctness  of  his 
statements,  even  although  they  should  fail  to  verify  them,  by 
repeated  experience ;  and  incline  them  rather  to  doubt  their  own 
capacity  in  exploring,  and  the  accuracy  or  acuteness  of  their 
perceptive  powers,  than  the  fidelity  of  the  records  which  he  has 
bequeathed  to  them. 

And  here  I  think  it  necessary  to  state,  in  the  most  distinct 
and  unequivocal  terms,  that  although  nothing  is  easier  than  for 
any  one  to  acquire  sufficient  evidence  of  the  truth  and  powers  of 
Auscultation,  it  is  only  by  long  and  painful  trials,  (inter  tcedia  et 
labores,  as  Avenbrugger  says  of  his  congenerous  discovery,)  that 
any  useful  practical  knowledge  of  it  can  be  acquired.  When, 
therefore,  we  hear,  as  we  sometimes  do,  that  certain  persons  have 
tried  the  stethoscope,  and  abandoned  it  upon  finding  it  useless  or 
deceptive ;  and  when  we  learn,  on  inquiry,  that  the  trial  has 
extended  merely  to  the  hurried  examination  of  a  few  cases,  with- 
in the  period  of  a  few  days  or  weeks ;  we  can  only  regret  that 
such  students  should  have  been  so  misdirected,  or  should  have  so 
misunderstood  the  fundamental  principles  of  the  method.  No 
conclusions  deduced  from  such  attempts — T  cannot  dignify  them 
with  the  term  experience, — can  have  any  weight  with  those  qual- 
ified to  judge  in  the  matter ;  they  can  only  be  added  to  the  heap 
of  false  facts,  as  they  have  been  called,  with  which  medicine 
and  indeed  every  department  of  human  knowledge,  is  overlaid 
and  which  are  the  characteristic  and  ready  offspring  of  minds  too 
feeble  to  be  habitually  conversant  with  the  general  principles,  and 
too  narrow  to  embrace  all  the  more  important  relations  of  the 
objects  of  their  inquiry. 

I  am  ready  and  willing  to  concede,  that  this  difficulty  of  at- 
taining a  complete  practical  knowledge  of  Auscultation  is  one 
of  the  greatest  drawbacks  to  its  value  ;  as  it  will  ever  prevent 
the  indolent  and  careless  from  making  themselves  masters  of  it 
But  I  will  venture  to  add,  that  no  one  who  has  once  mastered  its 
difficulties,  and  who  cultivates  his  profession  in  that  spirit  which 
its  high  importance  and  dignity  demand,  will  ever  regret  the 
pains  taken  to  overcome  them,  or  willingly  forego  the  «reat  ac{_ 
vantages  which  he  has  thereby  acquired. 


TRANSLATOR  S    PREFACE.  XI 

It  must  not  be  supposed  from  any  thing  I  have  stated,  that  I 
<im  inclined  to  consider  the  methods  of  diagnosis  discovered  by 
Avenbrugger  and  Laennec  as  all  in  all  ;  as  not  only  unerring 
in  their  nature,  but  also  sufficient  for  practical  purposes,  without 
any  aid  from  the  common  and  general  symptoms  of  diseases. 
So  far  is  this  from  being  the  case,  that  I  deem  it  necessary  in  this 
place  to  repeat,  what  I  have  substantially  declared  in  several  of 
the  notes  appended  to  the  work,  that  such  a  doctrine  is  both  false 
and  dangerous.  In  science,  as  well  as  in  religion  and  politics, 
over-zealous  and  injudicious  friends  are  often  more  injurious  to 
the  cause  they  advocate,  than  its  most  determined  enemies  ;  and 
in  regard  to  auscultation,  I  am  convinced  that  the  most  certain 
mode  of  preventing  its  general  adoption,  is  to  attempt  to  extend 
it  beyond  its  just  limits,  or  to  raise  its  credit  at  the  expense  of 
other  methods  in  more  general  use,  which  have  not  merely  the 
sanction  of  the  experience  of  ages,  but  the  still  stronger  support 
of  deep-rooted  prejudice  in  their  favor.  So  far,  indeed,  am  I 
from  advocating  its  exclusive  use,  that  (with  some  exceptions)  I 
would  lay  it  down  as  a  general  rule,  that  the  physician  ought,  in 
the  first  place,  to  endeavor  to  ascertain  the  nature  and  state  of  the 
disease  by  the  common  symptoms  alone,  and  that  it  should  be 
only  had  recourse  to  afterwards,  as  a  sort  of  experimentum  crusis, 
to  fortify  his  convictions  in  obvious  cases,  or  remove  his  doubts 
in  difficult  ones.  In  every  case,  however,  of  doubt  or  difficulty, 
or  even  simply  of  danger,  I  consider  the  use  of  the  stethoscope 
as  indispensable.  In  the  great  majority  of  such  instances,  it  will, 
at  once,  remove  all  obscurity  and  difficulty  ;  in  every  case  it  will 
communicate  to  the  mind  of  the  practitioner  a  degree  of  certain- 
ty, and  consequent  satisfaction  and  comfort,  which  no  combination 
of  mere  symptoms  can  inspire,  and  which  will,  in  most  cases, 
have  a  beneficial  influence  on  the  future  treatment. 

The  best  proof  of  the  value  of  Auscultation  is,  however,  found 
in  the  great  progress  which  the  practice  has  made  in  every  coun- 
try of  Europe,  as  is  sufficiently  evinced  by  the  medical  publica- 
tions of  the  last  few  years.  There  is,  indeed,  hardly  any  one  of 
the  civilized  nations  of  the  world,  which  cannot  now  afford  exam- 
ples of  its  acknowledged  utility,  either  in  its  publications  or  in  the 
practice  of  its  medical  professors.  France,  as  might  be  expected, 
has  taken  the  lead  in  this  respect.  The  records  of  her  medical 
literature  can  already  boast  of  several  works  not  unworthy  of 
coming  after  the  Treatise  on  Auscultation  ;  and  in  the  ranks  of 
her  most  eminent  practitioners,  are  several  well  qualified  by  their 
zeal  and  their  practical  skill,  to  succeed  its  lamented  author.  As 
claiming  especial  notice  in  this  respect,  I  must  mention  the  ex- 
tremely valuable  works  of  MM.  Andral,  Louis  and  Bertin,  so 
frequently  referred  to  in  my  notes.     Of  the  same  class  and  cha- 


*ii  translator's   PREFACE. 

racter  as  the  treatises  of  Corvisart,  Bayle  and  Laennec,  these 
volumes  are  (with  many  others  which  could  be  named)  splendid 
proofs  of  the  great  superiority  of  the  French  pathologists  over 
those  of  any  other  country  in  Europe,  and  entitle  their  authors 
to  the  highest  praise  for  zeal,  industry,  and  accuracy  of  research. 
The  work  of  M.  Andral,  more  especially,  is  fraught  with  the  most 
important  information  respecting  Auscultation. 

At  the  time  of  the  publication  of  my  Collection  of  Cases,  now 
nearly  four  years  since,  I  took  occasion  to  lament  the  little  pro- 
gress made  by  the  new  methods  of  diagnosis  in  this  country  ;  but 
I  have  reason  to  believe  that  they  were  at  that  time  practised  to 
a  greater  extent  than  I  was  then  aware  of.  Certain  it  is,  that 
since  the  period  alluded  to,  our  medical  literature  has  borne  suf- 
ficient testimony  to  their  increased  and  increasing  progress ; 
while  I  have  learned  from  other  sources,  how  extensively  and 
accurately  they  are  practised  by  many  physicians  and  surgeons,  of 
distinguished  talents,  in  England,  Scotland,  and  Ireland.* . 

But,  perhaps,  the  most  striking  tribute  rendered  to  Mediate 
Auscultation,  in  this  or  any  other  country,  and  one  which  seems 
likely  to  be  productive  of  the  most  important  results,  is  that  for 
which  it  is  indebted  to  the  present  enlightened  Director  General 
of  the  medical  department  of  the  British  army.  In  a  letter  with 
which  I  was  honored  by  Sir  James  Macgregor,  on  the  publication 
of  my  Collection  of  Cases  illustrating  the  use  of  the  Stethoscope 
and  Percussion,  he  informed  me  that  he  had  given  general  direc- 
tions to  the  medical  officers  of  the  army  to  make  trial  of  the  new 
methods,  and  to  report  the  result.  I  have  also  learnt  from  my 
friend  Sir  William  Burnett,  the  Physician  of  the  Navy,  that  no 
opportunity  is  lost  in  that  department  of  the  public  service,  in  re 
commending  the  use  of  the  stethoscope. 

The  translation  now  presented  to  the  public,  I  wish  to  be  con- 
sidered as  complete,  in  as  far  as  regards  the  chief  subject  of  the 
treatise.  The  Cases,  however,  needlessly  and  uselessly  diffuse  in 
the  original,  I  have,  in  almost  every  instance,  abridged.  In  dif- 
ferent parts  of  the  work,  also,  I  have  here  and  there  omitted  a 
few  passages  which  seemed  to  have  no  necessary,  or  at  least  useful 
connexion  with  the  subject  of  it.  The  whole  of  the  Treatise, 
indeed,  I  have  endeavored,  not  to  abridge,  but  to  condense,  by 
the  use  of  as  concise  a  mode  of  expression  as  possible  ;  and  if  I 
have  succeeded  in  my  intentions,  my  translation,  I  flatter  myself, 
will  be  more  valuable  than  if  it  had  been  strictly  literal ;  a  good 
deal  of  the  original  being  written  in  a  diffuse  and  verbose  style 
by  no  means  commendable  in  a  work  of  science.  By  these  means 
and  by  the  use  of  a  much  larger  page  and  closer  form  of  printing 

*  See  the  Bibliographical  notice  on  Auscultation  at  the  end  of  the  volume. 


TRANSLATOR  S    PREFACE.  Xl^ 

I  have  been  enabled  to  comprehend  the  whole  in  one  volume, 
containing  only  about  the  same  number  of  pages  as  one  of  the  two 
volumes  of  the  original. 

Having  taken  considerable  pains  to  be  accurate  during  the  pro- 
cess of  translation,  and  having  scrupulously  revised  the  sheets 
before  going  to  press,  with  the  original  in  my  hand,  I  hope 
it  will  be  found  that  my  version  is,  at  least,  faithful.  If,  in 
addition,  I  have  succeeded  generally  (I  do  not  flatter  myself  to 
have  done  so  always)  in  presenting  the  sense  of  my  author  in 
tolerably  good  English,  in  spite  of  the  unfavorable  influence  of 
a  foreign  idiom  constantly  before  me,  I  have  attained  all  that  I 
had  in  view  ;  and,  indeed,  almost  all  that  the  translator  of  a  scien- 
tific work  could  desire.  It  is  only  in  the  department  of  polite 
literature,  that  elegance  of  style  can  be  considered  essential. 
The  public,  however,  has  a  right  to  expect  from  all  those  who 
undertake  to  inform  it,  at  least  correctness  of  language ;  and  I 
sincerely  wish,  for  the  credit  of  the  medical  literature  of  this 
country  at  the  present  time,  that  it  could  always  lay  claim  even 
to  this  degree  of  merit. 

In  the  notes  which  I  have  appended  to  the  translation,  my 
object  has  been  rather  to  be  useful  than  to  appear  learned. 
Many  of  them  are  expressly  designed  for  the  student ;  and  for 
these,  1  trust  every  allowance  will  be  made  by  the  more  experi- 
enced and  learned  practitioner ;  since  I  could  not,  in  justice, 
overlook  the  advantages  of  those  who  will,  in  all  probability, 
constitute  a  very  numerous  class  of  my  readers,  and  who,  cer- 
tainly, stand  most  in  need  of  a  guide  and  counsellor.  With  a 
little  more  trouble,  I  could  have  made  my  annotations  much  more 
extensive  ;  but  I  was  unwilling  to  load  my  pages  either  with  the 
results  of  my  own  experience,  when  these  were  in  accordance 
with  the  statements  in  the  text,  or  with  the  mere  parade  of  autho- 
rities however  respectable.  It  will,  no  doubt,  be  found  that  I 
have  omitted  to  notice  many  passages  in  authors,  at  least  as  im- 
portant as  those  to  which  I  have  referred ;  and  some,  probably, 
of  consequence  to  the  satisfactory  elucidation  of  the  subjects  un- 
der consideration.  Another  opportunity  may  perhaps  occur  for 
remedying  this  deficiency ;  and  in  the  mean  time,  I  hope  that 
the  very  considerable  labor  necessarily  incurred  in  the  mere  trans- 
lation of  the  work,  undertaken  and  completed  amid  the  exigencies 
of  an  active  practice,  will  be  received  by  the  profession  as  some 
apology,  if  not  excuse,  for  this  and  other  imperfections. 

October.,  1827. 


PREFACE 


TO    THE     THIRD    EDITION. 


It  is  extremely  gratifying  to  me  to  be  called  upon  for  a  new  edi- 
tion of  my  Translation,  within  a  period  of  a  little  more  than 
twelve  months  from  the  publication  of  the  former.  This  rapid 
sale  may,  I  hope,  be  considered  as  affording  satisfactory  evidence 
of  two  things  by  which  I  am  necessarily  much  interested, — I  mean, 
the  increasing  attention  of  the  Profession  to  the  subject  of  Auscul- 
tation, and  the  approval  of  my  efforts  to  excite  and  gratify  this 
attention.  As  I  am  thoroughly  convinced,  that  the  general  diffu- 
sion, among  medical  men,  of  the  great  pathological  and  practical 
truths  contained  in  this  treatise,  is  calculated  extensively  to  bene- 
fit mankind,  I  have  derived  from  the  very  favorable  manner  in 
which  my  book  has  been  received,  a  pleasure  far  above  that  which 
could  result  from  any  success,  however  great,  of  a  mere  literary 
kind.  The  consciousness  of  being  the  instrument  of  good  to 
many,  hallows  any  occupation,  and  gives  dignity  even  to  the  hum- 
ble labors  of  the  Translator.  As  such,  therefore,  I  am  proud  to 
have  my  name  associated,  in  the  medical  annals  of  this  country, 
with  the  great  name  of  Laennec,  although  bearing  and  claiming 
no  higher  title  than  that  of  a  sincere  admirer  and  faithful  disciple. 

In  preparing  this  edition  for  the  Press,  I  have  carefully  revised 
the  whole,  and  made  such  alterations  and  improvements  in  vari- 
ous parts  of  it,  as  seemed  to  me  desirable.  I  have  modified  some 
of  the  notes  in  the  former  edition,  and  have  added  several  new 
ones,  which  I  hope  will  be  found  valuable. 

[  confidently  trust  that  the  work  in  its  present  form,  will  con- 
tinue to  be  found  deserving  the  patronage  which  it  has  hitherto 
so  liberally  received. 

J.  F. 

Chichester,  December  18,  1828. 


PREFACE 


TO    THE    FOURTH    EDITION. 


In  once  more  presenting  the  great  work  of  Laennec  to  the  mem- 
bers of  the  medical  profession  in  this  country,  it  is  gratifying  to 
me  to  be  able  to  state  that  they  will,  in  my  opinion,  find  it  very 
considerably  improved  in  this  the  Fourth  Edition.  The  text  is 
enlarged  by  the  addition  of  numerous  short  passages  and  several 
entire  cases,  not  translated  in  the  former  editions  ;  while  the  style 
of  the  whole  has  been  carefully  examined,  and  altered  where  it 
seemed  to  require  amendment. 

During  the  six  years  which  have  elapsed  since  the  publication 
of  the  last  edition,  much  has  been  done  to  increase  our  knowledge 
of  the  pathology  of  diseases  of  the  chest,  and  to  improve  the 
means  of  their  successful  investigation ;  and  it  has  been  my  duty, 
as  annotator  and  commentator,  to  put  the  reader  in  possession  of 
all  such  improvements  as  were  known  to  me,  and  seemed  likely 
to  be  useful  or  interesting  to  him.  The  great  mass  of  additional 
matter  in  the  notes  will,  at  least,  evince  that  I  have  not  shrunk 
from  the  labor  incident  to  this  part  of  my  task ;  and  I  trust  that 
it  will  be  found,  on  examination,  that  my  efforts  have  not  been 
altogether  misdirected  or  barren  of  useful  results. 

In  accomplishing  my  task  I  have  derived  great  advantage  from 
the  notes  appended  by  Dr.  Meriadec  Laennec  to  the  new  Parisian 
edition  of  his  cousin's  Treatise.*  All  of  these  which  possessed 
either  pathological  or  practical  interest,  I  have  translated  ;  but  I 
have  left  nearly  untouched  the  very  copious  annotations  which  he 
has  appended  to  various  chapters  under  the  head  of  Recapitula- 
tion of  the  Auscultatory  Signs.  This  I  have  done,  partly,  be- 
cause these  recapitulations,  although  excellent  in  themselves,  are, 
as  their  name  implies,  mere  repetitions  of  statements  already  given 
in  the  text,  and  partly,  because  they  have  already  appeared  in  our 
language  in  a  separate  form.f 

*  Traite'  de  l'Auscultation,&c  Troiseme  Edition,  Augmentee  de  Notes, 
par  Meriadec  Laennec,  D.  M.  P.  ancien  chef  de  Clinique  de  la  Faculto  de  M6d- 
ecine,  Medecin  de  Dispensaires,  &c.  Paris,  1831.     3  vols.  8vo. 

t  A  Manual  of  Percussion  and  Auscultation.  Composed  from  the  French  of 
Meriadec  Laennec.     By  J.  Sharp.     Lond.  1832.     12mo. 

c 


XV1U  TRANSLATOR  S  PREFACE. 

Numerous,  however,  and  important  as  are  the  annotations  de- 
rived from  the  industrious  researches  of  my  co-editor,  and  from 
the  writings  of  Dr.  M.  Laennec's  zealous  and  learned  country- 
men, my  readers  will  find  themselves  under  still  greater  obliga- 
tions to  the  eminent  pathologists  of  our  own  country  who  have, 
of  late  years,  so  successfully  cultivated  the  fields  of  auscultation 
and  thoracic  pathology  ;  and  I  must  here  in  a  more  particular 
manner  express  my  acknowledgments  to  my  distinguished  friends 
Drs.  Carswell,  Clark,  Hope,  Stokes,  Townsend  and  Williams, 
from  whose  respective  works,  published  in  a  distinct  form,  as 
well  as  from  their  numerous  and  elaborate  communications  to 
the  Cyclopaedia  of  Practical  Medicine,  I  have  derived  so  much 
valuable  information.  Dr.  Hope's  elaborate  and  excellent  Trea- 
tise on  the  Diseases  of  the  Heart,  and  Dr.  Williams's  scientific 
little  work  on  the  Signs  of  the  Diseases  of  the  Lungs  and  Pleura, 
have  been  of  especial  service  to  me  ;  and  I  should  not  be  doing 
justice  to  my  sense  of  their  importance  if  I  did  not  strongly  re- 
commend them  to  all  who  are  interested  in  the  subject  of  the  pres- 
ent Treatise. 

Having,  from  these  and  other  similar  sources,  and  from  the 
stores  of  my  own  experience,  done  my  best,  consistently  with  the 
prescribed  limits  of  the  work,  to  make  good  some  original  defects 
in  the  treatise,  and  to  supply  the  wants  which  the  progress  of 
medical  science  has  created  since  the  date  of  its  first  publication, 
I  would  fain  hope  that  the  present  edition  may  appear  to  com- 
petent judges,  to  present  a  tolerably  accurate  and  complete  view 
of  the  actual  state  of  our  knowledge  of  the  Pathology,  Diagnosis, 
and  Treatment  of  Diseases  of  the  Chest.  I  may,  at  least,  ven- 
ture to  assure  the  reader  that  whatever  is  found  defective  in  any 
of  these  particulars,  will  be  supplied  from  the  sources  indicated 
in  the  bibliographical  references,  now  for  the  first  time  appended 
to  the  different  articles  in  the  treatise. 

I  will  only  further  add,  in  conclusion,  and  as  an  acknowledg- 
ment due  to  the  Publisher,  that  notwithstanding  the  great  quan- 
tity of  additional  matter,  the  expense  of  engraving  new  plates, 
and  the  superior  typographical  elegance  of  the  work,  it  is  offered 
to  the  profession  at  a  price  very  considerably  below  that  of  the 
preceding  editions. 

J.  F. 

Chichester,  Sept.  15,  1834. 


LIFE    OF    THE    AUTHOR. 


Rene'  The'ophile  Hyacinthe  Laennec  was  born  at  Quimper,  in 
Lower  Brittany,  on  the  17th  February,  1781.*  His  father  was  an 
advocate  in  the  provincial  courts,  and  held  some  appointments  un- 
der government,  in  his  native  county.  He  appears  to  have  been  a 
man  of  some  talent,  and  is  said  to  have  possessed,  along  with  the 
art  of  the  poet,  not  a  little  of  the  instability  and  thoughtlessness 
often  associated  with  that  character.  Fortunately  his  son  was  the 
heir  of  the  more  solid  parts  of  his  genius ;  without  his  wit,  but  with- 
out his  volatility.  At  an  early  age  he  was  committed  to  the  charge 
of  his  uncle,  his  father's  brother,  a  respectable  ecclesiastic,  at  that 
time  in  charge  of  the  parish  of  Elian,  in  the  vicinity  of  Quimper. 
But  the  valuable  superintendence  of  this  gentleman  was  in  a  short 
time  lost  to  young  Laennec,  first  by  the  promotion  of  his  uncle  to 
an  higher  office  in  the  church,  and  afterwards  by  his  exile  in  the 
general  proscription  of  the  clergy,  on  the  breaking  out  of  the 
French  Revolution.  He  was  then  transferred  to  the  care  of  another 
uncle,  Dr.  Laennec  of  Nantes ;  a  circumstance  which,  no  doubt, 
gave  the  color  to  his  subsequent  life,  and  was  the  remote  cause  of 
all  his  future  greatness.  Dr.  Laennec  was  a  man  of  the  highest 
respectability  both  as  to  talent  and  conduct,  and  directed  the  studies 
of  his  nephew  with  the  interest  and  affection  of  a  parent.  The 
young  scholar  did  credit  to  his  friends  and  teachers ;  having  ob- 
tained considerable  distinction  among  his  fellows  at  the  chief  school 
of  the  department  of  the  Lower  Loire,  whither  he  had  been  sent  by 
his  uncle.  Having  completed  his  preparatory  studies  at  this  semi- 
nary, his  thoughts  naturally  turned  towards  physic  as  a  profession. 
He  willingly  engaged  himself  as  the  pupil  of  his  uncle,  and  entered 
upon  the  study  of  his  future  profession  with  the  zeal  inherent  in 
his  character,  and  with  success  indicative  of  his  subsequent  emi- 
nence. Besides  the  instructions  derived  from  his  uncle,  who  was 
at  that  time  senior  physician  of  the  hospital,  and  afterwards  Pro- 
fessor of  Medicine  and  Materia  Medica  at  Nantes,  he  attended  the 
courses  of  anatomy  given  by  the  surgeons  of  the  same  establish- 
ment, and  is  said,  even  at  this  early  age,  to  have  shown  a  decided 
predilection  for  morbid  anatomy  and  clinical  observation. 

*  All  the  principal  statements  contained  in  this  Sketch  are  derived  from  two 
short  Memoirs  of  the  Author's  Life,  published  by  MM.  Kergaradec  and  Bayle, 
and  from  a  MS.  chiefly  in  the  form  of  Notes  on  these,  which  I  had  the  honor  of 
receiving  from  Dr.  Meriadec  Laennec,  the  cousin  and  friend  of  the  subject  of  the 
present  notice. 


XX  LIFE    OF    THE    AUTHOR. 

Towards  the  close  of  the  year  1799  he  was  for  a  short  period  en- 
gaged in  the  public  survice,  and  officiated  as  assistant  surgeon  in 
the  military  hospitals  at  that  time  established  at  Nantes :  he  like- 
wise attended,  in  this  capacity,  the  detachment  of  The  Army  of  the, 
West,  which  marched  into  The  Morbihan,  to  quiet  the  troubles  at 
that  time  prevalent  there.  In  the  following  year,  having  resigned 
his  temporary  appointment  in  the  army,  he  went  to  Paris  in  order 
to  complete  his  medical  education.  He  immediately  attached  him- 
self to  the  clinical  school  of  La  Charite,  then  under  the  direction 
of  the  celebrated  Corvisart,  whose  notice  and  regard  the  active  and 
zealous  student  had  soon  the  good  fortune  to  engage.  Among  his 
fellow-pupils  at  this  time,  was  Bayle,  afterwards  so  distinguished 
for  his  pathological  researches,  more  especially  in  phthisis :  and 
as  he  was  Laennec?s  senior  by  several  years,  and  moreover  his  per- 
sonal friend,  there  is  little  doubt  that  his  example  must  have  had 
considerable  weight  in  fixing  the  attention  of  the  young  student  on 
his  own  favorite  pursuit.  Although  attached  in  a  more  particular 
manner  to  the  clinic  of  La  Charite,  Laennec  attended  the  various 
medical  lectures  at  that  time  delivered  at  The  School  of  Medicine ; 
and,  as  well  by  his  talents  and  superior  knowledge  of  the  learned 
languages,  as  by  his  great  zeal  and  assiduty  in  medical  pursuits,  he 
speedily  attained  a  marked  degree  of  distinction  among  the  crowd 
of  students  then  frequenting  the  Parisian  hospitals.  His  remarka- 
ble industry  at  this  period  is  best  evinced  by  the  fact,  that  during 
the  first  three  years  of  his  attendance  as  pupil  of  La  Charite,  he 
drew  up  a  minute  history  of  nearly  four  hundred  cases  of  disease ; 
and  the  talent  and  discrimination  of  the  youthful  reporter  must  ap- 
pear equally  conspicuous,  when  it  is  known  that  these  very  cases 
furnished  the  groundwork  of  all  his  future  researches  and  discove- 
ries. This  fact  (which  I  give  on  the  authority  of  his  cousin,  Dr. 
Meriadec  Laennec)  ought  to  prove  a  stimulus  to  the  industry  of  all 
students  in  their  attendance  on  hospital  practice,  and  should  teach 
them,  that,  to  record  every  important  case  they  meet  with,  is  not 
only  a  most  useful  labor  at  the  time,  but  may  eventually  lead,  as 
in  the  case  of  the  subject  of  this  memoir,  to  results  of  the  highest 
consequences  to  themselves  and  their  profession.  At  an  early  period 
of  his  labors,  he  began  to  communicate  some  of  their  results  to  the 
public,  and  was  honored  with  signal  marks  of  professional  distinc- 
tion. In  the  year  1802,  being  then  in  his  twenty-first  year,  he  pub- 
lished in  the  Journal  de  Mtdecine,  at  that  time  conducted  by  Corvi- 
sart, Leroux,  and  Boyer,  several  papers  of  singular  merit ;  and 
likewise  obtained  the  two  chief  prizes  in  medicine  and  surgery, 
granted  by  the  Minister  of  the  Interior,  through  the  then  Institute 
of  France.  His  first  paper  consists  of  an  interesting  case  of  dis- 
eased heart,  and  appeared  in  the  number  for  Messidor,  an.  x. 
(1802*).  Two  months  later,  in  the  same  year  (Fructidor,  an.  x.) 
he  published  his  Histoires  d1  Inflammation  du  Peritoinei,  consisting 
of  a  series  of  cases  detailed  in  a  very  clear  and  satisfactory  manner, 
illustrated  by  much  learned  annotation,  and  terminated  by  general 
conclusions,  specifying  the    anatomical  character  and  signs  of  peri- 

*  Journ.  de  Med.  t.  iv,  p.  295.  t  lb.  p  499. 


LIFE    OF    THE    AUTHOR.  XXl 

tonitis  in  a  more  accurate  manner  than  had  been  previously  done. 
This  memoir,  which  has  the  great  merit  of  being  six  years  anterior 
to  the  publication  of  Broussais's  Phlegmasics  Chroniques,  is  well 
worthy  the  attention  of  pathologists.  It  bears  the  impress  of  great 
learning  and  talent,  and  could  not  fail  to  give  great  promise  of 
subsequent  eminence  in  its  youthful  author.  He  appears,  about 
the  same  time,  to  have  commenced  his  career  as  a  critic  or  review- 
er, (a  character  in  which  he  was  afterwards  conspicuous  for  many 
years,)  as  there  appears  in  the  same  volume  of  the  Journ.  de  Med. 
(p.  565)  a  review  of  the  French  translation  of  Benjamin  Bell's 
Treatise  on  the  Venereal  Disease,  bearing  (as  is  usual  in  France) 
the  name  of  the  reviewer,  R.  T.  H.  Laennec,  at  its  head. 

In  the  same  year  he  gave  as  striking  a  proof  of  his  superior 
knowledge  of  natural  anatomy,  as  he  had  previously  done  of  his 
pathological  knowledge  in  his  Essay  on  Peritonitis,  by  the  publica- 
tion of  his  Lettre  sur  les  tuniques  qui  enveloppent  certains  visceres, 
addressed  to  Dupuytren,  then  principal  anatomist  in  the  School  of 
Medicine.*  In  this  memoir  his  object  was  to  d^yiibe  more  par- 
ticularly than  had  been  done  before,  peculiar«M0i^W;ertain  viscera, 
particularly  the  liver,  spleen,  and  kidney,  seatecHseneath  the  peri- 
toneal coat,  and  constituting  the  proper  sheath  of  their  vessels  : — 
if  we  admit  this  tunic  to  be  distinct  from  the  cellular  layer  which 
unites  the  peritoneal  to  the  parenchyma  of  the  organs,  we  must  * 
consider  Laennec  as  the  discoverer  of  it.  This  paper,  like  all  his 
earlier  productions,  is  distinguished  by  much  literary  research,  and 
a  spirit  of  liberality  towards  his  predecessors.  About  the  same 
time  he  pointed  out  a  mode  whereby  the  lining  membrane  of  the 
ventricles  of  the  brain  may  be  demonstrated,  a  thing  which  had 
been  previously  admitted  only  from  analogy  ;f  and  described  a 
synovial  capsule,  before  unobserved,  situated  between  the  acromion 
process  and  top  of  the  humerus. \  He  likewise  contributed  several 
reviews  to  the  same  journal,  of  which  he  afterwards  (in  1804)  be- 
came chief  editor,  and  continued  to  be  so  till  1809.  In  1803, 
while  still  a  student  and  a  youth,  he  began  a  course  of  lectures  on 
pathological  anatomy,  which  he  continued  for  three  years  with 
considerable  success  ;  animated  in  his  exertions  not  merely  by  his 
native  zeal  in  the  pursuit,  but  by  a  noble  spirit  of  rivalry  between 
himself  and  Dupuytren,  who  commenced  a  course  of  the  same 
kind  at  the  very  same  time.  In  February,  1804,  he  read  a 
memoir  on  that  variety  of  hydatids  termed  by  him  Accphalocysts 
before  the  Faculty  of  Medicine.  A  sketch  of  this  memoir  was  pub- 
lished at  the  time  in  the  first  vol.  of  the  Bulletins  de  la  Faculte,  p. 
131,  and  was  printed  at  length  in  their  Memoires,  which  have 
hitherto  remained  unpublished.  On  the  11th  June,  in  the  same 
year,  he  obtained  his  degree  of  Doctor  in  Medicine.  His  thesis, 
entitled  "  Propositions  sur  la  doctrine  d'Hippocratc  appliquee  a  la 
midicinc-pratique"  proved  him,  according  to  the  expression  of  M. 
Bayle,  to  be  no  less  skilled  in  the  knowledge  of  the   Greek  lan- 

*  Journ.  de  Med.  t.  v.  p.  589,  (Ventose,  an  xi.) 

t  Journ.  de  Med.  t.  v.  p.  254.  X  Ibid.  p.  442. 


XXII  LIFE    OF    THE    AUTHOR. 

guage  than  deeply  read  in  the  writings  of  the  father  of  physic.  M. 
Laennec  was,  indeed,  always  a  great  admirer  of  Hyppocrates  ; 
and  there  are  few  of  his  writings  in  which  this  admiration  is  not 
strongly  expressed.  After  his  graduation,  he  entered  formally 
upon  the  practice  of  medicine,  and  continued  to  devote  himself  to 
this  and  his  medical  studies,  until  obliged  by  ill  health  to  relinquish 
both.  His  constitution,  naturally  feeble,  and  predisposed  to  dis- 
ease, was  unequal  to  the  labors  he  imposed  upon  himself:  and  as 
his  private  practice  increased,  he  felt  himself  under  the  necessity 
of  relinquishing  some  of  his  employments.  Accordingly  he  dis- 
continued his  course  of  pathological  anatomy  in  1806.  This  course 
attracted  considerable  attention  during  its  continuance,  and  was  in 
some  degree  founded  on  the  lecturer's  own  discoveries  and  re- 
searches. The  arrangement  of  it  was  quite  original,  and  indicated 
at  once  a  clear  and  a  comprehensive  mind.  It  was  long  the  inten- 
tion of  Laennec  to  publish  a  complete  work  on  morbid  anatomy, 
and  he  did  not  relinquish  the  idea  of  so  doing  for  several  years 
after  the  close  i^iis  course  of  lectures.  The  only  portions  of  the 
work,  howeverHB^jfcvere  ever  completed  have  been  subsequently 
published  as  separate  articles  in  the  Dictionnaire  des  Sciences  Midi- 
tales,  or  in  his  Traite  de  V Auscultation.  A  brief  exposition  of  the 
classification  adopted  by  him  was  read  at  the  Societi  de  VEcole  de 
Midecine,  in  Jan.  1805  (6  Nivose,  an.  xiii.,)  and  was  afterwards 
published  in  the  Journ.  de  Med.  t.  ix.  360.  Enlarged  and  somewhat 
altered,  it  subsequently  formed  'the  excellent  but  brief  article, 
Anatomie  Pathologique,  contributed  by  him  to  the  Diet,  des  Sc.  Med. 
(t.  ii.  p.  46.)  Among  other  discoveries  of  the  first  years  of  his  labors 
in  the  dissecting  room,  the  morbid  alterations  named  by  him,  En- 
cephaloid  Cancer,  and  Melanosis,  deserve  particular  notice  for  their 
importance.  Both  these  are  mentioned  by  him  in  the  memoir  read 
before  the  School  of  Medicine,  in  1805 ;  and  although  it  is  true 
that  the  former  was  previously  well  known  in  England,  having  been 
described  by  Burns  in  1800,  by  Hey  in  1803,  and  by  Abernethy  in 
1804,  the  subject  of  our  memoir  appears  to  have  been  totally 
ignorant  of  this  fact,  and  is,  therefore,  equally  entitled  with  these 
gentlemen  to  the  honor  of  having  discovered  it.  Besides  the  arti- 
cles mentioned,  and  numerous  reviews  which  he  published  in  the 
Journ.  de  Med.,  he  read  several  papers  before  the  Society  of  Medi- 
cine, and  likewise  communicated  some  valuable  articles  to  the 
Diet,  des  Sc.  Med.,  to  which  he  had  become  one  of  the  joint  con- 
tributors. The  articles  written  by  him  in  this  work  are  the  follow- 
ing :  Anatomie  Pathologique,  t.  ii.  p.  46 ;  Ascaridcs,  ibid.  p.  339 ; 
Cartilages  Accidentels,  t.  iv.  p.  123 ;  Degeneration,  t.  viii.  p.  201 ; 
Disorganization,  ibid.  p.  536 ;  Detrachyceros,  t.  x.  p.  43 ;  Encipha- 
loide,  t.  xii.  p.  165 ;  Filaire  t.  xv.  p.  493.  This  last  article  was  pub- 
lished in  1816,  and  closed  his  connexion  with  that  great  but  unequal 
work,  from  which  he  was  called  off  by  more  urgent  duties,  and  by 
one  of  the  most  brilliant  and  important  discoveries  that  had  ever 
illustrated  practical  medicine.  Previously  to  this  period,  however, 
namely  in  the  year  1814,  it  is  deserving  honorable  mention,  that  he 
was  one  of  the  physicians  who  volunteered  their  services  in  one  of 


LIFE    OF    THE    AUTHOR.  XXU1 

the  Parisian  hospitals  (La  Salpetriere)  at  that  time  filled  with  sick 
and  wounded  soldiers.  On  this  occasion,  owing  to  his  knowledge 
of  the  Armorican  or  Breton  language,  he  had  an  opportunity  of 
being  particularly  serviceable  to  some  of  his  unfortunate  country- 
men. Among  the  young  soldiers,  who  at  that  unhappy  period 
crowded  the  hospitals,  overwhelmed  at  once  with  bodily  fatigue 
and  distress  of  mind,  there  happened  to  be  a  great  number  of  con- 
scripts from  Bretagne,  who  did  not  know  one  word  of  French,  and 
whose  sufferings  in  consequence,  were  greatly  and  fatally  aggrava- 
ted by  nostalgia  of  the  worst  description.  These  poor  fellows  were 
speedily  congregated  in  the  wards  under  the  charge  of  Laennec  ; 
where  they  derived  as  much  benefit  from  the  care  and  kindness  of 
their  countryman,  and  from  the  delight  of  being  understood  and 
spoken  to  in  their  native  language,  as  from  the  medical  skill  with 
which  they  were  treated. 

In  1816  Laennec  was  appointed  chief  physician  to  the  Necker 
Hospital,  the  duties  of  which  he  undertook  with  his  usual  zeal  and 
activity,  and  in  which  he  was  speedily  rewarded  for  all  his  labors 
by  his  immortal  discovery  of  Mediate  Auscuhptida.  7  It  is. surprising, 
as  he  himself  observes,  that  this  discovery  had  never  been  made  be- 
fore :  especially  as  it  is  certain  that  Hippocrates  was  accustomed, 
in  certain  cases,  to  apply  the  ear  to  the  chest,  with  the  view  of  as- 
certaining the  presence  of  water  in  this  cavity ;  and  the  wonder  be- 
comes still  greater,  after  the  great  analogous  discovery  of  Avenbrug- 
ger.  For  some  remarks  on  the  practice  of  Hippocrates  in  this 
particular,  I  refer  to  the  article  on  Immediate  Auscultation  in  the 
following  treatise ;  and  for  the  author's  own  narrative  of  his  discov- 
ery of  Mediate  Auscultation,  I  refer  to  page  5  of  the  Introduction. 
From  the  time  of  his  discovery,  M.  Laennec  appears  to  have  devo- 
ted himself  with  astonishing  perseverance  to  the  pefection  of  the 
new  system  of  diagnosis  which  he  founded  on  it :  and  with  a  degree 
of  success,  and  a  fertility  of  results  much  more  remarkable  than 
the  discovery  itself,  and  indicative  of  the  finest  powers  of  invention, 
the  truest  characteristic  of  genius.  In  June  1818,  that  is,  less  than 
two  years  after  the  discovery,  the  author  read  a  memoir  before  the 
Academy  of  Sciences,  containing  the  outlines  of  his  method ;  and 
in  September  of  the  following  year  he  published  the  first  edition  of 
his  immortal  work,  in  two  volumes  octavo,  under  the  title  of  De 
V Auscultation  Midiate,  ou  TraiU  du  Diagnostic  des  Maladies  des 
poumons  et  du  Coeur,  fonde  principalement  sur  ce  nouveau  moyen  d? ex- 
ploration. 

The  labor  necessary  to  perfect  his  discovery  and  to  compose  his 
Treatise,  was  nearly  fatal  to  the  author;  and  he  was  under  the  ne- 
cessity of  breaking  through  all  his  engagements,  and  retiring  to  the 
country,  within  a  month  after  the  publication  of  his  work.  This 
was  at  first  received  by  the  profession  with  considerable  distrust; 
and  the  new  mode  of  diagnosis,  and  especially  the  instrument,  was 
attempted  to  be  turned  into  ridicule.  Indeed,  but  for  the  admira- 
ble descriptions  of  the  diseases  contained  in  the  work,  which  proved 
the  vast  industry  and  talent  of  the  author,  and  rendered  his  vol- 
umes infinitely  valuable,  whether  his  diagnostics  were  true  or  false, 


XXIV  LIFE    OF    THE    AUTHOR. 

it  seems  probable  tbat  tbe  discovery  of  Laennec,  like  that  of  Aven- 
brugger,  might  have  been  allowed  to  fall  into  temporary  oblivion. 
As  it  was,  however,  the  work  soon  excited  a  great  sensation  in  Pa- 
ris, and  the  new  method  of  diagnosis  was  hailed,  especially  by  the 
younger  members  of  the  profession,  as  a  discovery  fraught  with  the 
most  splendid  results.  Fortunately,  also,  the  whole  of  the  author's 
investigations  had  taken  place  in  the  eye  of  the  public,  and  before 
numerous  and  zealous  pupils,  both  able  and  willing  to  prosecute 
the  methods  which  they  had  seen  productive  of  such  wonderful  ef- 
fects in  the  hands  of  their  master.  These  pupils,  with  a  warmth 
natural  to  their  years,  soon  spread  the  practice  of  auscultation  not 
only  in  France,  but  conveyed  it,  in  some  degree,  into  every  coun- 
try of  Europe. 

Meanwhile  the  author  had  retired  to  his  native  province,  worn 
down  with  bodily  and  [mental  disease.  His  retreat  was  a  country- 
house  of  his  own,  near  Quimper  (named  in  the  language  of  the 
country  Kerlouaruec,  the  place  of  foxes,)  on  the  shores  of  the  bay 
of  Douarnenez.  His  illness  at  this  time  presented  none  of  the 
characters,  of  that  fHiieh  subsequently  terminated  his  life.  Accord- 
ing to  the  account  transmitted  to  me  by  Dr.  M.  Laennec,  it  was  a 
slow  nervous  fever,  without  any  sign  of  severe  local  disease.  The 
principal  symptoms  were — dyspnoea  with  puerile  respiration,  and 
without  cough ;  dyspepsia  and  anorexia,  but  without  redness  of  the 
tongue,  nausea,  vomiting,  diarrhoea,  or  pain  in  the  abdomen ;  a  ten- 
dency to  vertigo  but  without  headache;  great  muscular  debility 
with  disposition  to  fainting,  and  lowness  of  spirits  amounting  almost 
to  tedium  vitce ;  these  two  last  symptoms  were  the  most  prominent, 
and  the  most  distressing  of  all.  The  truly  nervous  character  of 
Laennec's  disorder,  was  sufficiently  proved  by  the  event  of  the  case ; 
as  it  was  removed  in  a  surprisingly  short  time  by  his  residence  in 
the  country.  The  pure  air  of  the  sea-shore ;  the  freedom  from  care 
and  mental  labor;  exercise,  particularly  hunting,  of  which  he  was 
passionately  fond,  and  the  delightful  associations  of  childhood  and 
youth,  re-awakened  amid  the  very  scenes  which  had  given  them 
birth,  spread  their  enchantments  over  his  wasted  frame  and  spirits, 
and  restored  the  energy  of  both.  It  is  no  wonder,  therefore,  that 
he  was  unwilling  to  return  to  Paris.  He  believed  that  he  could  not 
preserve  his  health  there  more  than  six  months ;  and  it  was  only  the 
great  regard  he  bore  to  his  family,  and  the  powerful  influence  of  his 
religious  principles,  that  had  sufficient  weight  to  make  him  leave 
his  retreat.  In  returning  to  the  metropolis,  we  are  assured  that  he 
was  solely  influenced  by  the  idea  that  he  might  be  of  use  to  man- 
kind, by  extending  the  knowledge  of  auscultation.  M.  Laennec 
reached  Paris  on  the  15th  November,  1821,  and  immediately  re- 
sumed his  duties  in  Necker  Hospital.  He  likewise  commenced  a 
course  of  Clinical  lectures,  chiefly  illustrative  of  his  new  discoveries, 
which  were  attended  by  many  zealous  students,  and  particularly 
by  foreigners.  Two  months  after  his  return  to  the  capital,  he  was 
selected  by  M.  Halle"  (who  retired  on  account  of  ill  health)  for  his 
successor,  as  physician  in  ordinary  to  the  Duchess  of  Berri ;  and  on 
the  death  of  this  gentleman,  in  March  following,  he  was  also  ap- 


LIFE    OF    THE    AUTHOR.  XXV 

pointed  by  royal  authority,  his  successor  in  the  Chair  of  Med- 
icine in  the  College  of  France.  This  appointment  took  place  on 
the  last  day  of  July,  1822 ;  and  the  new  professor  delivered  his  first 
lecture  on  the  2nd  of  December  in  the  same  year.* 

Owing  to  disturbances  among  the  pupils,  countenanced  by  some 
of  the  professors,  and  originating  in  causes  of  a  political  nature,  the 
Faculty  of  Medicine  was  suppressed,  by  royal  authority,  in  the  be- 
ginning of  November,  1822,  and  was  re-established  early  in  the 
succeeding  February.  M.  Laennec,  on  this  occasion,  was  nomina- 
ted Professor  of  Clinical  Medicine,  and  began  his  course  of  Lec- 
tures, at  LaCharite,  on  the  1st  of  April  of  the  same  year.  A  high- 
er office  had  been  offered  to  him,  namely,  that  of  Member  of  the 
Royal  Council  of  Public  Instruction ;  but  he  preferred  the  appoint- 
ment which  offered  him  an  opportunity  of  continuing  his  researches 
and  extending  the  knowledge  of  his  discoveries.  "It  was  here 
(says  M.  Bayle)  at  La  Charite,  surrounded  by  his  patients,  that  we 
had  an  opportunity  of  admiring  at  once,  the  delight  he  took  in  the 
instruction  of  his  pupils,  the  deep  interest  he  had  in  the  improve- 
ment of  his  art,  and  his  courage  in  surmounting  habitual  sufferings 
in  order  to  indulge  in  his  favorite  pursuits.  His  painful  efforts 
were  rewarded  in  a  manner  the  most  agreeable  to  him,  by  a 
numerous  concourse  of  pupils,  and  even  of  distinguished  phy- 
sicians, whom  his  great  reputation  attracted  to  Paris  from  every 
country  in  Europe."  "We  saw  him  (says  M.  Rergaradec)  in  his 
new  office,  displaying  the  same  zeal  and  the  same  exactness  which 
distinguished  the  performance  of  all  his  duties.  He  showed  the 
utmost  courtesy  and  complaisance  to  all  who  were  attracted  to 
his  clinic  by  his  great  name  and  the  wish  to  perfect  themselves  in 
the  use  of  the  stethoscope.  His  auditors  consisted  of  the  natives 
of  every  country  in  civilized  Europe,  many  of  whom  had  come 
purposely  to  Paris,  with  the  view  of  judging  personally  of  the  new 
method  of  exploration,  and  of  seeing  the  illustrious  individual 
who  was  entitled  to  the  two-fold  honor  of  having  discovered  and 
brought  it  to  perfection." 

M.  Laennec's  assiduity  in  teaching,  did  not  make  him  neglect 
the  work  on  which  the  great  reputation  he  now  enjoyed  was  chiefly 
founded.  The  first  edition  of  the  Treatise  on  Auscultation  had 
been  for  some  time  out  of  print ;  he,  therefore,  set  about  preparing 
a  new  one,  with  the  utmost  care.  This  was  a  work  of  great  labor  ; 
as  the  alterations  made  in  the  second  edition  constitute  it  rather  a 
new  treatise,  than  an  improved  copy  of  the  old.  He  not  only 
altered  the  entire  plan  of  the  work,  but  he  submitted  all  his  facts 
to  a  new  examination.  He  corrected  some  mis-statements,  cleared 
up  many  doubtful  passages,  and  perfected  many  points  of  investi- 
gation which  had  been  only  commenced  at  the  time  of  his  first 
publication  :  he  likewise  added  the  important  subject  of  Treatment 
to  his  previous  account  of  the  anatomy  and  diagnosis  of  the  dis- 
eases. The  new  work  having  thus  received  the  most  careful,  and, 
as  it  proved,  the  final  revision  of  the  author,  appeared  in  the  be- 
ginning of  1826.     In  like  manner  as  at  the  time  of  the  publication 

*  This  was  afterwards  published  in  the  Archives  Gen.  de  Med.  for  Jan.  1823- 

D 


XXVI  LIFE    OF    THE    AUTHOR. 

of  the  former  edition,  the  physical  powers  of  the  author  seem  to 
have  been  completely  exhausted  by  the  exertions  he  made  to  finish 
his  work,  combined  with  the  pressure  of  his  other  engagements  of 
a  public  and  private  nature.  Scarcely  was  his  book  published, 
when  the  disease  under  which  he  had  been  laboring  for  some  time, 
increased  with  so  much  rapidity  as  soon  forced  him  to  relinquish  all 
his  employments.  He  had  been  long  subject  to  a  dry  cough,  to 
transient  pains  in  the  right  side,  and  to  a  diarrhoea,  which,  when  it 
kept  within  moderate  bounds,  he  considered  rather  beneficial  than 
otherwise.  In  the  beginning  of  April,  these  symptoms  became 
aggravated,  with  the  addition  of  fever  and  dyspnoea  and  considera- 
ble emaciation.  Bloodletting  and  other  appropriate  measures  were 
had  recourse  to,  only  with  very  temporary  benefit;  and  he  resolved 
to  make  trial,  once  more,  of  the  means  from  which  he  had,  on  a 
former  occasion,  derived  such  signal  benefit.  He  reached  his 
country  residence,  after  a  fatiguing  journey,  (which  was  rendered 
still  more  distressing  by  an  accident  from  which  he  suffered  a  se- 
vere local  injury,)  and  in  circumstances  very  different  from  those 
attending  his  former  return.  The  pleasure  of  once  more  finding 
himself  in  the  place  of  his  birth  and  of  his  affection,  the  freshness 
of  the  sea-air,  in  which  he  had  the  most  remarkable  confidence, 
the  freedom  from  all  professional  cares  and  duties,  and  gentle  air- 
ings in  a  carriage,  seemed  for  a  short  space  to  re-animate  both  his 
exhausted  spirits  and  his  wasted  frame.  But  the  relief  was  brief 
and  illusive  ;  the  bad  symptoms  all  returned  with  redoubled  force ; 
and  he  died  on  the  13th  of  August,  1826,  in  the  forty-fifth  year  of 
his  age. 

There  can  be  no  doubt  that  the  disease  of  which  Laennec  died  was 
phthisis  pulmonalis ;  and  it  is  somewhat  curious  that  he  shared  the 
fate  of  some  of  his  most  illustrious  predecessors,  in  falling  a  victim 
to  a  disease,  the  nature  of  which  he  had  taken  particular  pains  to 
illustrate.  Lancisi  and  Corvisart  died  of  diseased  heart :  and  his 
own  friend  Bayle  sunk,  like  himself,  under  the  ravages  of  the  dis- 
ease of  which  he  had  been  the  most  successful  illustrator,  and  of 
the  inevitable  fatality  of  which  he  had  been  the  most  strenuous  as- 
sertor.  M.  Laennec's  case  presented  all  the  external  symptoms  of 
consumption  ;  and  its  nature  was,  moreover,  fully  confirmed  by  the 
very  art  which  he  had  himself  discovered.  Before  he  left  Paris, 
Drs.  Recamier  and  Meriadec  Laennec  discovered  imperfect  but 
evident  pectoriloquy,  under  the  clavicle,  and  in  the  supra-spinal  fossa 
of  the  left  side ;  and  at  Quimper,  Drs.  Ambrose  Laennec  and  Ol- 
livry  observed  the  same  in  the  infra-spinal  fossa.  There  can,  there- 
fore, be  no  question  that  tubercles  in  the  state  of  softening,  existed  in 
his  lungs.  Sometime  before  his  death,  his  medical  attendants  had 
likewise  discovered  a  hard  irregular  tumor  in  the  abdomen,  the  pre- 
cise nature  of  which  was  never  ascertained,  as  the  body  was  not  ex- 
amined after  death.  This  appears  a  rather  singular  omission,  con- 
sidering the  eminence  and  character  of  the  man,  the  period  of  his 
death,  and  the  circumstances  of  his  life.  I  am  informed  by  his 
cousin,  that  the  examination  did  not  take  place,  because  there  was 
no  medical  person  near  him  at  tbc  time  of  his  decease. 


LIFE    OF    THE    AUTHOR.  XXV11 

M.  Laennec  was  of  diminutive  size  from  birth,  but  not  a  sufferer 
from  disease  in  the  earlier  parts  of  his  life.  He  grew  up  small  in 
stature,  very  thin,  but  of  greater  muscular  powers  than  his  figure 
promised.*  During  the  latter  years  of  his  life,  he  was  attenuated 
in  a  most  remarkable  degree,  insomuch  that  it  was  matter  of  as- 
tonishment to  every  stranger  that  he  could  undergo  the  exertions 
which  his  duties  required.  In  estimating  the  value  of  his  labors, 
it  is  necessary  to  keep  in  view  the  state  of  his  health ;  for  if  great 
results  were  produced  under  the  constant  pressure  of  disease,  it  is 
reasonable  to  suppose  that  his  mind  was  capable  of  much  greater 
efforts,  if  it  had  happily  been  united  with  a  material  fabric  of 
greater  vigor.  M.  Laennec  was  married  only  two  years  before  his 
death,  and  had  no  children.  His  widow  has  received  from  Gov- 
ernment a  pension  of  3000  francs  per  annum.! 

M.  Laennec  was  a  man  of  the  greatest  probity,  habitually  obser- 
vant of  his  religious  and  social  duties.  He  was  a  sincere  Christian, 
and  a  good  Catholic,  adhering  to  his  religion  and  his  church 
through  good  report  and  bad  report.  "  His  death  (says  M.  Bayle) 
was  that  of  a  Christian.  Supported  by  the  hope  of  a  better  life, 
prepared  by  the  constant  practice  of  virtue,  he  saw  his  end  ap- 
proach with  much  composure  and  resignation.  His  religious  prin- 
ciples imbibed  with  his  earliest  knowledge,  were  strengthened  by 
the  conviction  of  his  maturer  reason.  He  took  no  pains  to  con- 
ceal them  when  they  were  disadvantageous  to  his  worldly  interests ; 
and  he  made  no  boast  of  them,  when  their  avowal  might  have  been 
a  title  to  favor  and  advancement." 

In  the  practice  of  his  profession  he  was  extremely  liberal  and 
disinterested.  "  His  great  reputation,"  says  the  author  just  quoted, 
"  caused  his  services  to  be  required  by  persons  of  the  highest  sta- 
tion, as  well  as  by  the  poor  :  the  former  he  frequently  refused  to 
visit,  on  account  of  the  bad  state  of  his  health,  the  latter,  never. 
Nor  was  it  only  in  the  way  of  professional  advice  that  he  served 
the  poor  :  he  was  extremely  liberal  in  relieving  their  distresses 
with  pecuniary  aid,  and  in  a  manner  so  unostentatious,  that  it  is 
only  since  his  death  that  the  extent  of  his  bounty  has  come  to 
light." 

M.  Laennec  was  mild  and  agreeable  in  his  manners,  and  of  a 
quiet  and  even  temper.  His  conversation  was  at  once  lively  and 
instructive;  and  his  natural  humility  and  kindness  of  heart  were  in 
no  degree  lessened  by  his  great  reputation,  and  the  deference  that 
was  paid  to  him  in  the  after  years  of  his  life.     He  was  remarkable 

*  He  was  extremely  fond  of  field  sports,  and  took  great  delight  in  speaking 
of  them.  The  exertions  he  was  capable  of  making  on  these  occasions,  were 
remarkable  considering,  as  he  said,  "  1'air  chetif  de  son  extetieur."  For  in- 
stance ;  he  would  walk  eight  or  ten  leagues,  carrying  his  bag  and  gun;  and  on 
his  return  home,  in  place  of  resting  himself,  he  would  enter  into  some  species 
of  domestic  amusement. 

t  During  the  four  last  years  of  his  life  M.  Laennec  practised  only  as  a  consult- 
ing physician.  The  following  may  be  received  as  a  fair  approximation  towards 
the  amount  of  his  income  :  from  the  Facultc  de  Medecine  10,000  francs ;  from 
the  College  de  France  5,000  ;  from  the  Duchess  of  Berri  4000;  lrom  his- private 
practice  from  20  to  25,000. 


XXV1H  LIFE    OF    THE    AUTHOR. 

for  his  great  kindness  and  courtesy  to  foreigners,  particularly  thr 
English.  "The  homage  paid  to  the  talents  of  Laennec,"  says  Dr. 
Williams,  "  gives  me  a  gratification  that  almost  seems  personal ; 
and  I  doubt  not  that  this  feeling  is  shared  by  others  of  his  pupils, 
in  whom  his  urbane  and  amiable  deportment  created  a  sincere  re- 
gard for  the  man,  as  his  great  mental  abilities  excited  our  respect. 
His  great  talents  are  known  to  the  public  through  the  medium  of 
his  writings ;  but  those  who  attended  his  clinique  can  alone  appre- 
ciate the  wonderful  acuteness  of  perception  and  faculty  for  obser- 
vation, that  enabled  him  to  carry  his  discovery  to  the  degree  of 
perfection  in  which  he  left  it ;  and  they,  above  all,  witnessed,  felt, 
and  profited  by  the  solicitous  interest  which  he  showed,  to  make 
others  partake  of  its  inestimable  advantages."*  He  was,  however, 
less  popular  with  many  of  his  own  countrymen,  and  especially  with 
that  numerous  class  of  students  and  young  practitioners  who  were 
disciples  of  the  school  of  Broussais.  With  this  physician  M.  Laen- 
nec was  much  at  variance ;  and  a  controversy  was  for  some  time 
kept  up  between  them,  which  redounded  little  to  the  credit  of 
either.  It  must  be  admitted  that  M.  Laennec  was  not  free  from  pre- 
judices :  and  he  could  never  be  brought  to  render  full  justice  to 
the  doctrines  of  his  opponent.  This  is  much  to  be  regretted  :  for 
whatever  be  the  errors  of  that  system,  there  can  be  no  doubt  that 
to  it  the  world  is  indebted  for  many  valuable  discoveries  in  pathol- 
ogy, and  most  important  improvements  in  practical  medicine.  But, 
even  if  this  were  not  the  case,  the  system  deserved,  at  least,  at 
the  hands  of  a  philosopher,  to  be  examined  with  calmness,  and  its 
good  separated  from  its  evil  with  candor.  It  is  true  that  the  oppo- 
nents of  M.  Laennec  in  this  controversy,  were  more  violent,  and 
more  prejudiced  than  himself;  and  every  one  must  admit,  that  to 
retain,  amid  .the  excitations  of  controversy,  the  golden  mean  of 
truth  and  justice,  both  in  the  appreciation  of  the  facts  adduced  by 
our  adversary,  and  in  the  expression  of  our  arguments,  is  only  per- 
mitted to  few.  If  M.  Laennec  was  not  of  this  number,  it  ought 
certainly  to  be  a  matter  of  regret,  but  not  of  surprise. 

M.  Laennec  was  strongly  attached  to  the  existing  government  of 
France ;  and  was  a  decided  enemy  to  the  liberal  opinions  in  poli- 
tics, which  characterized  the  popular  party  in  that  country.  He 
is  even  reproached,  I  know  not  how  justly,  with  permitting  his  pre- 
judices, in  this  particular,  to  interfere  with  his  judgments  as  a  man 
of  science  and  a  professor.     I  hope  this  is  not  true. 

It  is  unnecessary,  after  what  has  been  already  stated  in  this 
sketch  to  dwell  long  upon  the  character  of  M.  Laennec  as  a  pathol- 
ogist and  medical  writer.  His  whole  life  was  devoted  to  professional 
pursuits ;  and  his  numerous  writings  afford  irrefragable  proof  of 
great  talent,  and  still  greater  industry.  His  genius  was  decidedly 
inventive,  and  his  turn  of  thought  original.  His  writings  are  gen- 
erally marked  by  sound  sense,  clear  views,  and  perspicuous  order ; 

*  A  rational  Exposition  of  the  physical  signs  of  the  diseases  of  the  lungs  and 
pleura.  Preface  to  the  first  edition,  p.  ix.  I  gladly  avail  myself  of  this  oppor- 
tunity of  strongly  recommending  this  very  valuable  work,  of  which  a  second 
edition  is  now  published,  to  the  notice  of  the  student  of  auscultation. 


LIFE    OF    THE    AUTHOR.  XXlX 

they  are,  however,  often  diffuse,  and  sometimes  needlessly  minute. 
He  was  an  excellent  Greek  and  Latin  scholar,  and  well  read  in  the 
best  medical  authors,  who  have  written  in  those  languages.  He 
was,  however,  by  no  means  equally  well  acquainted  with  modern 
medical  literature  ;  and  it  must  be  admitted  that  his  more  impor- 
tant writings  are  deficient  in  references  both  to  his  predecessors 
and  contemporaries.  This  may  be  partly  accounted  for  by  his  im- 
paired health,  and  partly  by  his  devoting  almost  all  his  time  during 
his  latter  years,  to  the  perfection  of  his  great  discovery.  He  was 
particularly  fond  of  the  Latin  language,  and,  in  different  parts  of 
his  writings,  regrets  that  it  is  not  still  made  the  general  medium  of 
intercourse  between  men  of  science.  He  was  accustomed,  in  the 
clinical  hospital,  to  dictate  his  reports,  and  to  address  the  pupils  in 
that  language  ;  partly  from  a  wish  to  conceal  from  the  patients  his 
opinions  of  their  complaints,  and  partly  from  his  having  always 
among  his  followers  a  good  many  foreigners  who  might,  perhaps 
be  unacquainted  with  the  French.  He  himself,  I  believe,  could 
speak  or  read  no  modern  language  but  his  own.  On  this  account 
he  was  sometimes  in  the  habit  of  corresponding  in  Latin.* 

However  eminent  as  a  pathologist,  however  qualified  for  accu- 
rate observation,  and  however  gifted  with  inventive  genius,  it  is  the 
opinion  of  many  who  had  opportunities  of  personal  observation, 
that  M.  Laennec  did  not  possess,  in  a  high  degree,  the  mental 
qualifications  necessary  to  constitute  a  great  and  skillful  practition- 
er. Even  in  the  very  class  of  diseases,  in  the  knowledge  of  whose 
pathology  and  signs  he  was   without  a  rival,  his  practice  was  not 

*  I  give  the  following  extracts  from  one  of  his  letters  to  myself,  as  a  specimen/ 
of  his  style.  They  are  likewise  in  place  here  :  the  first  as  relating  to  the  alte- 
rations in  the  second  edition  of  his  work :  and  the  last  as  illustrating  his  taste 
for  antiquarian  lore. 

Novam  interea  Auscultationis  intermedia  editionem  molior,  quam,  vergente 
anno,  publici  juris  faciam,  statimque  ac  in  lucem  prodibit,  ad  te  exemplarium 
raittam.  Non  nulla  in  ea  nova  erunt,  multa  clariora  aut  certiora.  Morborum 
praeterea  pectoris  curandorum  rationes,  usu  et  experientia  magis  comprobatas  ad- 
do.  Operis  ea  de  causa,  ordo  haud  parum  diversus,  nee  tamen  moles  multo  am- 
plior  erit :  nam  non  nulla  delere  aut  saltern  contrahere  in  animo  est.  Ideo  te 
non  nisi  postquam  opus  acceperis,  ad  novam  versionis  tuae  editionem  faciendam, 
accingendum  esse  arbitror;  tantum  historias  aegrotorum,  quas  in  prima  versione 
breviter  indicasti,  fuse  vertere  potes,  nam  de  his  parum  demam,  nisi  quoad  sty- 
lum  forsan  attinet 

P.S.  Signata  jam  epistola,  titulum  tuae  versionis  relegi,  et  video  te  Societati 
Geologicae  Cornubiensi,  a  scriptis  esse  aut  fuisse.  Si  forte  opusculum  aliquod 
antiqua  lingua  Cornubiensi  scriptum,  aut  quod  ejusdem  linguae  notitiam  aliquam 
contineret,  mihi  indicare  posses,  hoc  sane  me  incredibili  gaudio  perfunderet : 
nam  Armoi  ico-Britannus  sum,  vernaculasque  linguae,  id  est  Celticae,  ut  qui  max- 
imecupidus;  inter  cujus  dialectos,  Cornubiensis  etiamsi  abhinc  80  annos  aut 
circiter  penitus  obsoleverit,  tamen  philologia  Celticae  semper  pretioso  erit,  quia 
nexum  et  transitum  efficit  inter  Armoricanas  dialectos  et  Cambricas  (Vestrates 
dicunt,  ni  fallor  Welsh  language.)  Cambrica  scripta  majoris  momenti  fere  om- 
nia habeo  ;  sed  nihil  unquam  de  Cornubiensi  lingua  novi,  praeter  Lloydi  Arch- 
aologiam  Britannicam  eximium  opus,  sed  rarissimum,  quodque  semel  duntaxat 
in  bibliotheca  cujusdam  docti  viri,  videre  potius  quam  legere  licuit.  Si  vulgari- 
ora  quaedam  populi  Cornubiensis,  nuper  elapso  saeculo  prorsus  extincti,  monu- 
menta  adhuc  supersunt,  ut  puta.  cantilena?  populares,  aut  Christianarum  precum 
ljbelli,  gratissimum  mihi  faceres,  si  posses  aliquid  ejusmodi  ad  me  mittere 


XXX  LIFE    OF    THE    AUTHOR. 

reckoned  of  that  scientific  and  comprehensive  kind,  which  be- 
speaks a  mind  accustomed  to  take  in  at  once  the  whole  of  the 
morbid  processes,  and  quick  and  fertile  in  expedients  to  control  or 
relieve  them.  This  I  think  is  evident  from  his  own  work,  the  the- 
rapeutical parts  of  which  are  not  equal  to  the  others.  The  inven- 
tive turn  of  his  genius  seemed  to  have  frequently  misled  him 
from  the  most  obvious  and  best  path,  because  it  was  the  common 
one ;  and  in  his  search  after  novelty,  he  would  sometimes  adopt 
measures  of  very  doubtful  powers,  and  altogether  overlook  others 
of  known  and  approved  efficacy.  In  his  total  rejection  of  the  doc- 
trines of  Broussais,  he  certainly  committed  a  great  practical  error ; 
and  it  may  be  stated  generally  that  he  was  too  much  disposed  to 
sacrifice  scientific  views  to  empiricism. 

It  will  not  for  a  moment  be  supposed  that  the  kind  of  study  to 
which  M.  Laennec  was  more  particularly  devoted,  could  have  any 
effect  in  producing  this  result.  On  the  contrary,  it  is  a  thing  of 
daily  observation  that  men,  in  every  other  respect  most  highly 
qualified  by  natural  gifts,  and  by  general  education,  for  becoming 
good  practitioners,  are  rendered  the  very  reverse  by  their  mere  ig- 
norance of  pathology;  while  it  is  equally  common  to  find  others, 
most  deficient  in  the  natural  qualifications,  who  pass  for  good  prac- 
titioners, on  the  single  ground  of  their  pathological  knowledge.  It 
is  only  where  the  peculiar  but  indefinite  talent  for  the  art  of  practi- 
cal medicine,  is  combined  with  a  talent  for  close  observation,  and  a 
profound  knowledge  of  pathology,  that  we  find  the  physician  arrive 
at  the  greatest  degree  of  perfection  in  his  practice. 

The  most  remarkable  features  in  the  character  of  Laennec,  as  a 
practical  physician,  were  his  profound  acquaintance  with  organic 
diseases,  and  his  accurate  diagnosis  of  them  in  the  living  body. 
His  examinations  were  most  extensive  and  minute;  and  the  judg- 
ments he  founded  on  these,  were  such  as  might  be  expected  from 
his  industry  and  his  talents.  In  the  diagnosis  of  the  diseases  of  the 
chest,  he  was  universally  allowed  to  be  without  a  rival ;  and  it  is 
but  justice  to  state,  that  whatever  was  his  zeal  for  his  new  diagnos- 
tic measures,  he  seemed  always  more  desirous  of  ascertaining  the 
truth,  whatever  this  might  be,  than  to  obtain  results  that  might  re- 
dound to  the  honor  of  his  discovery. 

M.  Laennec  had  a  great  taste  for  mechanical  knowledge;  and  to 
this  bias  of  his  mind  we  are  probably  indebted  for  the  invention  of 
the  stethoscope.  He  was  also  conversant  with  practical  mechan- 
ics, and  used  to  make  his  own  stethoscopes. 

In  the  preceding  pages  I  have  already  named  the  pricipal  pub- 
lished writings  of  M.  Laennec  and  shall  now  subjoin  in  a  note,  a  list 
of  the  few  that  remain  unnoticed,*  excepting  his  Reviews.     These 

*  Observation  sur  un  Suicide,  Journ.  de  Med.  t.  v. 
Observation  sur  une  Maladie  du  Coeur,  Ibid.  t.  vii. 
Reflexions  sur  l'Hydrocephale  interne  aigu,  Ibid.  t.  xi. 
Observation  sur  un  Aneurisme  de  l'Aorte,  Ibid.  t.  xii. 

Fievres  intermittentes  pernicieuses  survenues  dans  la  convalescence  d'au- 
tres  maladies,  Ibid.  t.  xiv. 

Observation  sur  une  affection  aptheuse,  Ibid.  t.  xxii. 


LIFE    OF    THE    AUTHOR.  XXXI 

latter  productions  are  very  numerous  and  are  contained  principally 
in  the  Journ.  de  Med.  from  1804  to  1814.  Many  of  them  were 
written  when  the  author  was  still  very  young,  and  evince  consider- 
able talent.  Among  these,  an  article  on  the  system, of  John  Brown, 
(Op.  Cit.  t.  xi.,)  and  another  on  the  doctrines  of  Gall,  (Ibid.  t.  xii.,) 
both  written  in  his  25th  year,  are  excellent  in  their  kind.  The  fol- 
lowing brief  character  of  Brown  and  his  work  is  truly  drawn  and 
forcibly  expressed.  "L'ensemble  raeme  de  l'ouvrage,  quoique  sou- 
vent  mal  coordonne,  mal  lie  dans  ses  parties,  porte  cependant  par- 
tout  l'empriente  d'un  esprit  peu  ordinaire.  II  faut  du  genie  pour 
s'egarer,  ainsi  que  l'a  fait  Brown:  mais  dans  les  sciences  d'obser- 
vation,  le  genie  n'est  qu'un  don  funeste  de  la  nature,  lorsqu'il  n'est 
pas  accompagne  d'un  esprit  droit  et  juste.  Si  au  lieu  de  se  livrer 
a  son  imagination,  Broton  eut  puise  dans  les  ouvrages  des  maitres 
de  l'art  une  instruction  solide,  s'il  eut  consulte  la  nature  au  lieu  du 
raisonner  sur  ses  lois,  il  eut  rendu  ses  talens  aussi  utiles  aux  prog- 
res  de  la  medicine,  qu'ils  peuvent  lui  devenir  funestes  par  l'usage 
qu'il  en  fait."*  The  article  on  Gall,  which  may  fairly  bear  com- 
parison with  the  celebrated  one  by  Dr.  Gordon  in  the  25th  vol.  of 
the  Edinburgh  Review,  and  which  it  preceded  by  no  less  than  nine 
years,  is  forcibly  and  pleasantly  written;  but,  like  Dr.  Gordon's,  it 
was  conceived  in  a  spirit  unbecoming  the  philosophic  inquirer  after 
truth,  and  composed  in  evident  ignorance  of  the  principles  of  the 
doctrines  which  it  professes  to  expound.!  Laennec  was  a  true  Bre- 
ton, fond  of  his  country  and  consequently  jealous  of  its  honor.  It 
is  amusing  to  observe  in  one  of  his  reviews  (Journ.  de  Med.  t.  xi.  p. 
642)  the  high  tone  he  assumes  in  refuting  a  charge,  brought  by  a 
certain  writer  against  his  native  country,  for  being  infamous  for  an 
epidemic  itch.  He  solemnly  assures  us  that  if,  in  very  truth,  "  la 
gale  s'observe  quelquefois  en  Bretagne,  on  en  doit  moins  accuser  les 
localities  que  le  passage  et  le  sejour  des  matelots,"  &c. 

A  good  deal  has  been  said  respecting  the  manuscript  writings  left 
by  Laennec,  and  one  of  his  biographers  has  led  the  public  to  ex- 
pect the  early  publication  of  a  considerable  part  of  them  by  his 
cousin,  Dr.  Meriadec  Laennec,  to  whom  they  were  bequeathed. 
This  is  a  mistake.     The  following  is  an  account  of  them  transmit- 

Observation  sur  des  vers  ascarides,  &c.     Bulletins  de  la  Soc.  de  VEcole  de 
Med.  t.  i.  p.  53. 

Memoire  sur  les  vers  versiculaires,  Ibid.  p.  121. 

Seance  du  6  therrnidor  an.  xiii.     Memoire  sur  le  Cysticerque  a  double  vessie. 

du  51  frimaire  an.  xiv.     Note  sur  la  non-existence  du  tcenia  visceralis. 

du an.  xiv.     Note  sur  une  dilatation  partielle  de  la  valvule  mitrale. 

du  16  Avril  1807.     Memoire  sur  une  nouvelle  espece  d'hernie  (Intrapel- 

vienne.) 

du  19  Decembre  1810.     De  angina  pectoris  commentarius. 

*  Journ.  de  Med.  t.  xi.  p.  230. 

t  While  combating  his  author  on  the  score  of  the  number  and  division  of  his 
faculties,  the  reviewer  asks  why  there  is  not  one  for  dancing,  as  well  as  for  paint- 
ing, music,  &c.  and  pleasantly  adds,  that  the  doctor  might  have  high  authority 
for  the  new  organ.  The  first  Vestris,  he  informs  us,  having  just  finished  a  dance 
which  seemed  to  require  as  much  strength  as  agility,  was  asked  by  a  spectator 
if  he  was  not  much  fatigued — "  Monsieur,"  said  the  dancer,  "dans  notre  art  la 
fatigue  des  jambes  est  peu  de  chose  :  e'est  ceci,"  he  added,  pointing  to  his  fore- 
head— "  e'est  ceci  qui  travaille  !" — hum.  dc  Med.  t.  xii.  p.  2d5. 


XXX11  LIFE    OF    THE    AUTHOR. 

ted  to  me  by  Dr.  M.  Laennec.  1st.  A  very  great  number  of  Cases, 
indeed  the  whole  drawn  up  by  the  author  during  the  course  of  his 
medical  life.  They  are  quite  unfit  for  publication.  The  greater 
number  of  them  present  facts  now  well  known,  and  such  as  possess 
peculiar  interest  or  novelty,  have  been  already  made  use  of  by  the 
author  himself,  in  his  published  writings.  2nd.  Some  chapters  on 
Accidental  Productions,  partly  published  in  the  Diet,  des  Sc.  Med.  and 
in  his  Treatise  on  Auscultation.  3rd.  A  collection  of  notes  on  the 
whole  subject  of  medicine,  from  which  he  delivered  his  lectures  at 
the  College  de  France.  These  notes  are  in  general  very  short,  and 
very  unconnected,  and  could  only  be  reduced  to  a  connected  form 
by  much  labor  and  by  some  one  who  had  heard  the  discourses  and 
was  acquainted  with  the  lecturer's  method.  Dr.  M.  Laennec  says 
it  is  his  intention  to  attempt  this,  for  the  first  thirty  lectures ;  and  if 
he  succeeds  so  far  as  to  produce  a  work  not  unworthy  the  memory 
of  the  author,  he  will  publish  it ;  but  not  otherwise.  In  this  task 
Dr.  M.  Laennec's  labor  will  be  somewhat  analogous  to  my  own, 
but  still  more  difficult.  I  have  had  only  to  express  in  new  language 
ideas  already  expressed :  he  will  have  to  call  up  from  the  stores  of 
his  own  memory,  or  supply  from  his  own  judgment,  all  that  is  neces- 
sary to  convert  the  fragments  in  his  hands  into  a  connected  whole : 
both  of  us,  probably,  may  consider  it  the  dearest  labor  of  our  lives, 
and  our  highest  honor,  that  we  have  been  instrumental  in  spreading 
among  the  members  of  our  common  profession  throughout  the 
world,  the  knowledge  of  the  great  discovery  that  will  render  the 
name  of  Laennec  immortal. 


NOTICE  TO  BINDER. 
Plate  II to  face  the  Title. 


ANALYTICAL  TABLE  OF  CONTENTS. 


Advertisement  op  the  American  Publishers 
Dedication   ..... 
Translator's  Preface  to  the  Second  Edition 

to  the  Third  Edition 

to  the  Fourth  Edition 


Life  of  the  Author 
Introduction 


PART  FIRST. 


Of  the  Exploration  of  the  Chest 
Chap.  I.  Of  the  more  ancient  methods 

Sect.  1.  Manual  examination  of  the  chest 

Sect.  2.  Inspection  of  the  chest     . 

Sect.  3.  Succussion  of  the  chest 

Sect.  4.  Abdominal  pressure 
Chap.  II.  Of  Percussion     . 

Mode  of  percussion 

Character  of  the  sound  in  different 

III.  Of  Immediate  Auscultation 


Chap. 

Chap.  IV.    Of 
Sect.  1. 


Mediate  Auscultation 
Auscultation  of  the  respiration 
Vesicular  respiration 
Bronchial  respiration     . 
Cavernous  respiration 
Blowing  or  puffing  respiration 
Sect.  2.  Auscultation  of  the  voice 
Bronchophony    . 
Pectoriloquy 
iEgophony 
Sect.  3.  Auscultation  of  the  cough 
Sect.  4.  Auscultation  of  other  sounds 
Different  kinds  of  rhonchus   . 
The  moist  crepitous  rhonchus 
The  mucous  rhonchus 
The  tracheal  rhonchus  . 
The  dry  sonorous  rhonchus 
The  dry  sibilous  rhonchus 
Dry  crepitous  rhonchus 
Of  the  metallic  tinkling 
E 


Page 

. 

V 

. 

vii 

. 

.      ix 

. 

XV 

. 

.  xvii 

. 

xix 

• 

1 

9 

.     11 

11 

.     14 

17 

. 

.     17 

IB 

.    20 

parts 

22 

. 

.    27 

32 

g 

.     33 

34 

.     38 

40 

.     40 

41 

. 

.    43 

44 

, 

.    45 

53 

.     54 

55 

.     56 

57 

.     57 

60 

.     61 

61 

.     63 

XXXIV  CONTENTS. 

PART  SECOND. 
DISEASES  OF  THE  BRONCHI,  LUNGS,  AND  PLEURA. 

BOOK    FIRST. 

DISEASES  OF  THE  BRONCHI. 


Chap.  I.  Of  the  catarrhal  and  inflammatory  affections 

OF   THE    MUCOUS    MEMBRANE 

Sect.  1.   Of  the  acute  mucous  catarrh 
Anatomical  characters 
Symptoms  and  progress 
Occasional  causes     . 
Pathognomonic  signs 
Treatment    . 
Sect.  2.  Of  the  chronic  mucous  catarrh 
Symptoms  and  progress 
Treatment 
Sect.  3.  Of  the  pituitous  catarrh 

Idiopathic  pituitous  catarrh 
Acute  pituitous  catarrh 
Chronic  pituitous  catarrh 
Treatment    . 
Sect.  4.  Of  the  suffocative  catarrh 
In  old  persons 
With  oedema  of  the  lungs 
In  the  dying 
In  adults  and  children  . 
Treatment    . 
Sect.  5.   Of  the  dry  and  latent  catarrh 
Symptoms  and  progress 
Treatment 
Sect.  6.   Of  the  hooping  cough 

Treatment 
Sect.  7.   Of  Symptomatic  catarrh 
Chap.  II.  Of  Dilatation  of  the  Bronchi 
Anatomical  characters 
Occasional  causes 
Signs  and  symptoms 
Treatment 

Case  I. 
Case  II. 
Case  III.  . 
Case  IV. 
Chap.  III.  Of  Croup 

Anatomical  characters   . 
Symptoms     . 
Occasional  causes 


69 
70 
70 
73 
75 
75 
78 
80 
83 
84 
88 
88 
89 
90 
92 
93 
93 
93 
93 
94 
94 
96 
99 
101 
105 
108 
110 
115 
115 
117 
118 
120 
121 
122 
123 
124 
128 
129 
133 
136 


CONTENTS. 


XXXV 


Chap. 


Chap, 
Chap. 


Chap. 
Chap. 
Chap. 


Treatment    . 

IV.  Of  Bronchial  Hemorrhage 

Anatomical  characters 
Signs  and  symptoms 
Occasional  causes     . 
Treatment 

V.  Of  Polypus  of  the  bronchial  membrane 

VI.  Of  Ulcers  of  the  Bronchi 

Anatomical  characters 
Symptoms 
Treatment    . 

VII.  Of  alterations  of  the  bronchial  coats 

VIII.  Of  foreign  bodies  in  the  bronchi  . 

IX.  Of  diseases  of  the  bronchial  glands     . 


Page 

136 
140 
141 
141 
142 
143 
144 
146 
146 
147 
148 
149 
149 
151 


BOOK  second. 

DISEASES  OF  THE  LUNGS. 

Structure  of  the  lungs 

154 

Chap. 

I.  Of  hypertrophy  of  the  lungs 

.  159 

Chap. 

II.  Of  atrophy  of  the  lungs 

160 

Chap. 

III.  Of  emphysema  of  the  lungs 
Sect.  1.   Of  Vesicular  emphysema 
Anatomical  characters  . 
Occasional  causes     . 
Signs  and  symptoms 
Progress  of  the  disease 
Treatment 

Case  V.     . 

Case  VI. 

Case  VII. 

Case  VIII.      . 
Sect.  2.   Of  Interlobular  emphysema 
Anatomical  characters  . 
Occasional  causes     .. 
Signs 
Treatment    . 

.  161 

161 
.  161 

167 
.  169 

173 
.  175 

175 
.  176 

177 
.  178 

180 
.  180 

182 
.  183 

184 

Chap. 

IV.    Of  CEdema  of  the  lungs  . 
Anatomical  characters 
Symptoms  and  signs 

Case  IX.  . 

Case  X. 

Case  XI.  . 

Case  XII.       . 

.  186 

187 
.  188 

190 
.  191 

192 
.  193 

Chap. 

V.  Of  Pulmonary  apoplexy 

Anatomical  characters  . 
Signs  and  Symptoms 
Occasional  causes 
Treatment    . 

195 
.  196 

199 
.  204 

205 

XXXVI 


CONTENTS. 


Chap.  VI.  Of  pneumonia 

Sect.  1.  Anatomical  characters  of  the  acute 
First  degree  (engorgement) 
Second  degree  (hepatization) 
Third  degree  (purulent  infiltration) 
Abscess  of  the  lungs 
Resolution  of  pneumonia 
Duration  of  the  disease 
State  of  the  bronchi 
Sect.  2.  Signs  and  symptoms  of  Pneumonia 
Physical  signs     . 
Signs  of  suppuration 
Signs  of  abscess 
Signs  of  resolution    . 
Pulmonary  symptoms     . 
General  symptoms  and  progress 
Occasional  causes 
Sect.  3.   Of  gangrene  of  the  lungs 

Uncircumscribed  gangrene 
Circumscribed  gangrene 
Anatomical  characters  . 
Physical  signs 
Symptoms  and  progress 

Case  XII.  (bis.)    . 

Case  XIII.     . 

Case  XIV. 

Case  XV.       . 
Sect.  4.   Of  chronic  pneumonia 
Sect.  5.   Of  latent  and  symptomatic  pneumonia 
Sect.  6.   Treatment  of  pneumonia 
Bloodletting 
Derivatives   . 
Alkalis  and  Attenuants  . 
Purgatives  and  Emetics 
Tonics    .... 
Alteratives    . 

Tartar  emetic  in  large  doses 
Regimen 

Case  XVI.      . 
Chap.  VII.  Of  accidental  productions  developed  in  the 

LUNGS,    OR   PHTHISIS    PULMONALIS   . 

Sect.  1.  Anatomical  history  of  tubercles 

Miliary  tubercles 

Granular  tubercles 

Grey  tuberculous  infiltration     . 

Jelly-like  infiltration 

Encysted  tubercles 

Organic  changes  accompanying  phthisis 
Sect.  2.  Do  tubercles  arise  from  Inflammation  ?   . 

From  acute  pneumonia  ? 


Page 

208 

208 

209 

209 

211 

214 

218 

219 

220 

220 

220 

224 

224 

225 

228 

230 

232 

234 

234 

235 

235 

237 

238 

239 

239 

240 

241 

244 

246 

249 

250 

254 

255 

256 

256 

257 

259 

276 

277 

281 

284 
286 
288 
291 
291 
299 
304 
310 
310 


CONTENTS. 


XXXV11 


From  chronic  pneumonia  1  . 
From  catarrh  ?   . 
From  pleurisy  ? 
Sect.  3.  Is  phthisis  curable  ? 

Case  XVII. 
Case  XVIII. 
Case  XIX. 
Case  XX. 
Case  XXI. 
Case  XXII. 
Case  XXIII. 
Case  XXIV. 
Case  XXV. 
Case  XXVI. 
Sect.  4.   Occasional  causes  of  phthisis 
Sect.  5.  Physical  signs  of  tubercles 
Signs  of  crude  tubercles 
Signs  of  the  softening  of  tubercles 
Signs  of  the  discharge  of  tubercles 
Case  XXVII. 
Case  XXVIII.      . 
Sect.  6.  Symptoms  and  progress  of  phthisis 
Regular  manifest  phthisis     . 
Vomica  of  the  lungs 
Irregular  manifest  phthisis 
Latent  phthisis 
Acute  phthisis 
Chronic  phthisis 
Treatment  of  phthisis 
Means  of  softening  tubercles     . 
Empirical  means 
Palliative  treatment  of  symptoms 
Of  cysts  in  the  lungs 
Of  hydatids  in  the  lungs 

Treatment. 
Of  concretions  in  the  lungs 
Of  melanosis  of  the  lungs    . 
Encysted  melanosis 
Unencysted  melanosis 
Diffused  melanosis 

Case  XXX. 
Case  XXXI. 
Chap.  XII.  Of  encephaloid  tumor  of  the  lungs 
Encysted  medullary  tumor 
Unencysted  medullary  tumor 
Diffused  medullary  tumor 

XIII.  Of  diseases  of  the  pulmonary  vessels 

XIV.  Of  nervous  affections  of  the  lungs 
Sect.  1.  Neuralgia  of  the  lungs 
Sect.  2.  Nervous  dyspnoea 


Chap. 
Chap. 

Chap. 
Chap. 


Sect.  7. 


VIII. 
IX. 


X. 

XI. 


Chap. 
Chap. 


xxxvui 


CONTENTS. 


i.  Asthma  with  puerile  respiration 
ii.  Spasmodic  asthma 
Treatment    . 


Page 

436 
438 
447 


BOOK    THIRD. 


DISEASES  OF  THE  PLEURA. 

Chap.  I.  Of  pleurisy   .... 
Sect.  1.  Of  simple  acute  pleurisy 
Sect.  2.   Of  acute  hemorrhagic  pleurisy 
Sect.  3.   Of  gangrene  of  the  pleura 
Sect.  4.  Signs  and  symptoms  of  acute  pleurisy 
Physical  signs 
Double  pleurisy 
Local  symptoms 
General  symptoms 
Sect.  5.   Of  chronic  pleurisy 

Anatomical  characters 
Signs  and  symptoms 
Sect.  6.   Of  contraction  of  the  chest 

Case  XXXI.  (bis.) 
Case  XXXII. 
Case  XXXIII.     . 
Case  XXXIV. 
Sect.  7.   Of  circumscribed  or  partial  pleurisy 

Signs  and  symptoms 
Sect.  8.   Of  latent  pleurisy 
Sect.  9.    Treatment  of  pleurisy    . 
Operation  of  empyema 
Sect.  10.   Of  pleuro-pneumonia 

Pneumonia  with  slight  pleurisy 
Pleurisy  with  slight  pneumonia 
True  pleuro-pneumonia 
Chap.  II.  Of  hydrothorax 

Sect.  1.   Of  idiopathic  hydrothorax 

Signs  and  symptoms 

Sect.  2.   Of  symptomatic  hydrothorax 

Chap.  III.  Of  HjEmathorax      .  .  ..  , 

Treatment 
Chap.  IV.  Of  pneumothorax    . 

Sect.  1.  Anatomical  characters  of  pneumothorax 

Case  XXXV. 
Sect.  2.  Symptoms  and  signs  of  pneumothorax 

Case  XXXVI. 
Sect.  3.   Of  pneumothorax  ivith  liquid  effusion 
Case  XXXVII. 
Case  XXXVIII.  . 
Case  XXXIX. 
Case  XL. 


458 

459 

467 

472 

474 

474 

480 

480 

481 

483 

483 

485 

487 

492 

493 

495 

497 

500 

502 

503 

504 

508 

512 

513 

514 

515 

.  517 
518 

.  518 
521 

.  524 
526 

.  526 
526 

.  530 
532 

.  535 
537 

.  542 
544 

.  546 
547 


CONTENTS. 


XXXIX 


CaseXLI.     . 

Sect.  4.   Of  the  metallic  tinkling  as  a  sign 

CaseXLII.    . 
Treatment  of  pneumothorax 

Case  XLIII. 
Sect.  5.   Of  double  pneumothorax 
Chap.  V.  Of  accidental  productions  in  the  pleura 
Sect.  1.  Productions  with  effusion 
Sect.  2.  Solid  productions 

Case  XLIV. 
Sect.  3.  Productions  on  the  outer  surface 
Sect.  4.  Diaphragmatic  hernia 

PART  THIRD. 


Page 

548 
551 
554 
557 
559 
560 
561 
561 
562 
563 
565 
566 


DISEASES  OF   THE  HEART  AND  ITS  APPENDAGES. 


BOOK   FIRST. 


OF  THE  EXPLORATION  OF  THE  ORGANS  OF 
CIRCULATION. 


General  remarks          .... 

Chap.  I.  Of  the  extent  of  the  heart's  pulsations 

Chap.  II.  Of  the  shock  or  impulse   . 


Chap. 
Chap. 
Chap. 


Chap 
Chap 


III.  Of  the  sound 

IV.  Of  the  rythm 

V.  Of  anomalous  sounds 
Sect.  1.   Of  the  bellows-sound 

Proper  bellows-sound 

Sound  of  the  saw 

Musical  bellows-sound 

Causes  of  the  bellows-sound 
Sect.  2.   Of  the  purring-thrill 
Sect.  3.   Of  the  sound  of  pulsation  at  a  distance 

VI.  Of  palpitation  of  the  heart 

VII.  Of  irregularities  of  the  heart's  action 


Chap.  VIII.  Of  intermissions  of  the  heart's  action 


567 
570 
575 
579 
583 
600 
601 
601 
602 
602 
604 
611 
617 
619 
621 
622 


BOOK    SECOND. 


OF  DISEASES  OF  THE  HEART. 


Chap.  I.  Of  diseases  of  the  heart  in  general 

Sect.  1.   Of  the  symptoms  of  all  diseases  of  the  heart 
Sect.  2.   Of  the  changes  produced  on  other  organs 
Sect.  3.   Of  the  causes  of  diseases  of  the  heart 

Chap.  II.  Of  hypertrophy  of  the  heart 

Signs  of  hypertrophy  of  the  left  ventricle 


629 
629 
633 
637 
639 
643 


xl 


CONTENTS. 


Signs  of  hypertrophy  of  the  right  ventricle 
Chap.  III.  Op  dilatation  of  the  ventricles 

Anatomical  characters  . 

Signs  of  dilatation  of  the  left  ventricle 

right  ventricle 

Chap.  IV.  Of  dilatation  with  hyp.  of  the  ventricles 


Chap. 
Chap. 
Chap. 
Chap. 
Chap. 
Chap. 
Chap. 
Chap. 
Chap. 
Chap. 
Chap. 
Chap. 
Chap. 
Chap. 


Chap. 
Chap. 


Chap. 


Chap. 


Chap. 

Chap. 
Chap. 


Chap.  XXVI 


Chap. 


Signs       .  .  •    . 

V.  Of  dilat.  of  one  vent,  with  hyp.  of  the  other 

VI.  Of  dilatation  with  hypert.  of  the  auricles 

VII.  Of  partial  dilatation  of  the  heart 

VIII.  Of  induration  of  the  heart 

IX.  Of  softening  of  the  heart     . 

X.  Of  atrophy  of  the  heart  . 

XI.  Of  displacement  of  the  heart 

XII.  Of  malformation  of  the  heart 

XIII.  Of  carditis     ..... 

XIV.  Of  rupture  of  the  heart 

XV.  Of  fatty  disease  of  the  heart 

XVI.  Of  ossification  of  the  heart    . 

XVII.  Of  accidental  growths  in  the  heart 

XVIII.  Of  ossification  of  the  valves 
Sect.  1.  Anatomical  characters 

Sect.  2.  Signs      ...... 

Case  XL V. 
Sect.  3.   Ossification  of  the  internal  membrane  of  the  heart 

XIX.  Of  polypi  of  the  heart 

XX.  Of  inflammation  of  the  internal  membrane   . 

Redness  .  ... 

Pseudo-membranous  exudation 
Ulceration      .  . 

Polypous  concretions     . 

XXI.  Of  excrescences  on  the  valves,  &c. 

Case  XLVI.  . 
Case  XLVII. 
Case  XLVIII. 
Case  XLIX. 

XXII.  Of  pericarditis  . 
Sect.  1.  Anatomical  characters 
Sect.  2.  Signs     .  .  . 

XXIII.  Of  Hydropericardium 
Signs 

XXIV.  Of  pneumopericardium 

XXV.  Of  accidental  product,  in 
Case  L. 

Of  organic  affections  of 
The  coronary  vessels 
The  pulmonary  artery 
The  pulmonary  veins 

Of  the  organic  diseases 

Ossification  of  the  aorta 


XXVII. 
Sect.  1. 


THE    PERICARD. 


THE  VESSELS 


OF  THE  AORTA 


Page 

645 

648 

648 

649 

650 

652 

652 

654 

657 

659 

662 

663 

668 

669 

671 

675 

679 

682 

684 

686 

688 

688 

691 

695 

696 

702 

707 

707 

710 

711 

712 

716 

718 

720 

723 

724 

725 

726 

729 

734 

735 

736 

737 

738 

739 

739 

739 

740 

740 

740 


CONTENTS. 


Xli 


Sect.  2.  Malformation  of  the  aorta 
Sect.  3.  Aneurism  of  the  aorta 

Anatomical  characters 

Signs  ..... 

Chap.  XXVIII.  Of  the  treat,  of  diseases  of  the  heart 
Chap.  XXIX.  Of  nervous  affections  of  the  heart,  &c. 
Sect.  1.  Neuralgia  of  the  heart 

Angina  pectoris 

Treatment     .... 
Sect.  2.  Palpitation  of  the  heart 
Sect.  3.  Spasm  of  the  heart 
Sect.  4.  Nervous  affections  of  the  arteries 

Neuralgia      .... 

Preternatural  pulsation 

Spasm,  with  bellows-sound 

Treatment 


Page 

742 
742 
742 
744 
748 
755 
755 
756 
759 
762 
764 
764 
764 
764 
767 
768 


APPENDIX. 


Of  the  application  of   auscultation  to    other   cases   be- 
sides   DISEASES   OF   THE    CHEST     .  .  .  769 

Sect.  1.   Of  the  diagnosis  of  pregnancy  .  .  769 

Sect.  2.   Of  the  diagnosis  of  other  diseases     .  .  773 

1.  Fractures  ....  773 

2.  Urinary  calculi  .  .  .  775 

3.  Abscess  of  the  liver  .  .  .  775 

4.  Diseases  of  the  tympanum,  Sfc.  .  775 

5.  Diseases  of  animals         .             .             .  776 
Explanation  of  the  plates               .            .            .  783 


CONTENTS 


PRINCIPAL   NOTES.* 


Page 

Auscultation  prophesied  by  Hooke  and  indicated  by  Double 

before  the  publication  of  Laennec's  Treatise  .  .         4 

Different  forms  of  the  Stethoscope  ...  8 

Utility  of  Manual  Examination  of  the  Chest  .  .       13 

Value  and  mode  of  using  mensuration  of  the  Chest  .  14 

Value  of  Inspection  as  a  means  of  Diagnosis  .  .        17 

Capacity  of  the  lungs  to  contain  air,  as  a  test  of  their  soundness       18 
Biographical  notice  of  Avenbrugger  ...  19 

Of  covering  and  exposing  the  chest  during  percussion  .       20 

Of  the  regional  subdivision  of  the  surface  of  the  chest      .  24 

Of  mediate  percussion  .  .  .  .  .26 

Relative  value  of  mediate  and  immediate  auscultation       .  31 

M.  Reynaud  on  aegophony     (M.  L.)  .  .  .48 

Dr.  Williams  on  the  cause  of  aegophony  .  .  50 

Reasons  for  using  the  word  rhonchus  for  rale  .  .55 

The  translator's  classification  of  the  different  kinds  of  rhonchus       55 
Of  the  nature  and  cause  of  the  crepitous  rhonchus  .  56 

Of  the  cavernous  rhonchus       .  .  .  .  .59 

Of  the  sound  of  friction     (M.  L.)  .  .  .       65,  66 

Of  the  treatment  of  catarrh     .  .  .  .  .       80 

Of  the  employment  of  fumigations  and  balsams  in  catarrh  85 

Of  the  use  of  chlorine  gas  in  catarrh     (M.  L.)     .  .  86 

Of  the  use  of  colchicum  and  galvanism  in  catarrh      .  .       87 

Of  the  author's  classification  of  bronchial  diseases  and  of  the 
suffocative  catarrh  .  .  .  .  .  96 

Of  the  dry  catarrh  as   the  cause  of  asthma,  and   of  the  pre- 
vention and  treatment  of  the  latter  .  .  .     103 
Opinions  of  authors  respecting  the  seat  and  nature  of  hoop- 
ing cough             ......  107 

Of  the  treatment  of  hooping  cough     .  .  .  .     109 

Literature  of  hooping  cough  .  .  .  .  109 

Of  the  state  of  the  mucous  membranes  in  fever  .  .113 

Literature  of  catarrh  and  bronchitis  .  .  .  114 

*  The  notes  to  which  the  letters  M.  L.  are  appended,  are  either  wholly  or  in 
part  by  Dr.  Meriadec  Laennec ;  all  the  others  are  by  the  Translator. 


CONTENTS. 


xliii 


Page 


Tr.) 


118 
128 
132 
135 
137 
137 
139 
139 
145 
146 
148 
150 
165 
173 

174 
174 
180 
185 
186 
194 
197 
198 
200 


Andral  and  Williams  on  the  nature  and  cause  of  dilatation  of 
the  bronchi  ...... 

Of  the  knowledge  of  croup  by  the  ancients 

Of  the  relation  of  croup  to  cynanche  maligna 

Of  the  discrimination  of  true   and  false  croup  (M.  L.,  &, 

Dr.  Cheyne  on  blood-letting  in  croup 

Of  local  applications  to  the  air  passages  in  croup  (M.  L.) 

Of  the  use  of  calomel  in  croup 

Literature  of  croup 

Of  the  bronchial  polypus       .... 

Louis  and  Hastings  on  ulcers  in  the  bronchi 

Of  ulcerations  of  the  larynx  and  trachea 

Morbific  effects  of  the  inhalation  of  dust 

Andral  and  Piedagnel's  opinions  on  empyema  (M.  L.) 

Cause  of  the  dry  crepitous  rhonchus  (M.  L.)     . 

On  pulmonary   empyema  in  hares,  hawks,  &c.     Opinions  of 
Sir  J.  Floyer's,  &c.  .... 

Sir  John  Floyer's  proposal  for  curing  broken  wind 

Frequency  of  vesicular  emphysema 

Of  the  sound  of  friction  as  a  sign  of  emphysema  (M.  L.) 

Literature  of  emphysema  of  the  lungs 

Treatment  of  oedema  of  the  lungs  (M.  L.  &  Tr.,) 

Analogy  of  pulmonary  and  cerebral  apoplexy  (M.  L.) 

Of  the  terminations  of  pulmonary  apoplexy  (M.  L.)     . 

Of  the  history,  nature,  and  causes  of  pulmonary  apoplexy 

M.  Rousset's  sign  of  the  complication  of  pulmonary  apoplexy 
with  pneumonia  (M.  L.)         .  .  .  •         203,204 

Drs.  Clark  and  Brous^ais  on  certain  effects  of  blood-letting      .  206 

Literature  of  pulmonary  apoplexy       .... 

Of  the  cause  and  nature  of  the  granular  appearance  of  the  lungs 
in  pneumonia  ....•• 

Of  the  impression  of  the  ribs  on  inflamed  lungs 
Andral's  idea  of  a  vesicular  pneumonia  (M.  L.) 
Of  the  relative   frequency  of  inflammation  in  the  upper   and 

lower  lobes  of  the  lungs     . 
Of  the  relative  frequency  of  inflammation  in  the  right  and  left 
lungs    ....-••• 
Rareness  of  pulmonary  abscess         . 
Rareness  of  pulmonary  abscess  (M.  L.) 
Andral  and  Williams  on  the  crepitous  rhonchus 
Of  the  value  of  the  crepitous  rhonchus  as  a  sign  in  pneumonia  222 
On  the  difficulty  of  detecting  central  pneumonia 
On  certain  forms  of  expectoration  in   pneumonia 

importance  of  observing  this  in  general     . 
Influence  of  the  season  in  producing  pneumonia 
Relation  of  pneumonia  to  the  age  of  the  subjects 
Of  chronic  pneumonia — its  rareness 
Of  pneumonia  in  phthisis     ■•  • 

Of  pneumonia  from  absorption  of  pus    . 
Of  bloodletting  in  the  early  stages  of  pneumonia 
Of  bloodletting  in  the  later  stages  of  pneumonia 


210 
211 
212 

213 

213 
215 
216 
221 


and  on    the 


230 
233 
234 

245 
248 
249 
250 
251 


Xliv  CONTENTS. 

Page 

Of  local  bloodletting  in  pneumonia  .  252 

Of  blisters  in  pneumonia  (31.  L.  &  TV.,)         .  .         254,  255 

Of  the  alkaline  treatment  of  pneumonia       •  •  •         255 

Of  the  use  of  purgatives  in  pneumonia  .  256 

Of  the  use  of  calomel  and  opium  in  pneumonia       .  •         257 

Of  Dr.  A.  Laennec's  experience  of  tartar  emetic  (M.  L.)         •  265 
Impropriety  of  emetics  in  pneumonia  complicated  with  gastric 
irritation    .  .  .  .  .  •  •         270 

Of  the  treatment  of  pneumonia  with   tartar  emetic  in  large 
doses  ......-•  272 

Of  low  diet  in  pneumonia      .....         276 

Literature  of  pneumonia  .  ...  280 

Of  the  similarity  of  granulations  and  tubercles         .  .         288 

Of  the  nature  and  origin  of  tubercles  (M.  L.)    .  .  .292 

Dr.  Carswell's  opinions  respecting  tubercle  .  .         293 

Identity  of  grey  granulations  and  yellow  tubercles  (M.  L.)       .  300 
Relative  frequency  of  tubercles  in  the  two  lungs      .  .         300 

Relative  frequency  of  tubercles  in  other  organs  (31.  L.)  .  304 

Proportional  frequency  of  intestinal  ulcers  in  phthisis  .         306 

State  of  the  mucous  membranes  in  phthisis  (31.  L.)      .  •  307 

Proportional  frequency  in  phthisical  subjects,  of  organic  affec- 
tions in  other  organs  besides  the  lungs      .  .  .         308 
Of  the  secretion  of  tubercles  in  the  air-cells  (31.  L.)     .  .  315 
Of  catarrh,    &c.  considered    as  the   cause  of  tubercles  in   the 
lungs           .....••         317 

Different  opinions  of  the  origin  and  nature  of  tubercles  .  318 

Of  cicatrices  in  the  lungs      .....         330 

Of  the  geographical  prevalence  of  phthisis         .  •  •  341 

Relation  of  haemoptysis  to  pulmonary  tubercles  (3f.  L.  «fc  Tr.)  347 
Of  the  depressing  passions  as  a  cause  of  phthisis      .  .         348 

Of  the  contagion  of  phthisis        .....  350 

Relation  of  phthisis  to  the  age  of  the  individual  (31.  L.  &  Tr.)  353 
Relation  of  phthisis  to  sex     .....         353 

Of  the  state  of  the  respiration  in  the  early  stage  of  phthisis      .  365 
Of  perforation  of  the  lungs  in  phthisis  .  .  .         365 

Actual  value  of  auscultation  as  a  means  of  diagnosis  in  phthisis  369 
Of  pleuritic  pains  in  phthisis      .....  375 

377 

.  382 

384 

.  385 

388 

.  389 

390 

.  391 

392 

.  392 

396 

.  398 


Of  the  expectoration  in  phthisis 

Of  diarrhoea  in  phthisis 

Of  latent  phthisis       ..... 

Of  the  progress  and  duration  of  phthisis 

Of  bloodletting  in  phthisis     .... 

Of  issues  in  phthisis         .... 

Of  iodine  in  phthisis  .... 

Of  the  use  of  chlorine  gas  in  phthisis  (M.  L.  &  Tr.) 

Of  hydrocyanic  acid  in  phthisis 

Of  change  of  climate  in  phthisis 

Importance  of  prophylactic  treatment  in  phthisis    . 

Literature  of  phthisis  pulmonalis 

Dr.  Carswell  on  the  progress  of  melanosis  .  .  .        411 

On  the  variety  of  melanosis  termed  liquid  (M.  L.  &,  Tr.)        .  413 


CONTENTS.  Xlv 

Page 

Chemical  analysis  of  the  matter  of  melanosis  (M.  L.  &,  Tr.)      415 
Relation  of  the  matter  of  melanosis  to   the  black    pulmonary 

matter  and  the  coloring  matter  of  blood  (M.  L.  &  Tr.) .         416 
Chemical  analysis  of  the  black  pulmonary  matter  .  .  418 

Dr.  Carswell's  classification  of  melanosis     .  .  .         419 

Literature  of  melanosis  .....  423 

Opinions  respecting  encephaloid  cancer  (M.  L.)     .  .         429 

History  of  encephaloid  cancer  .....  430 

Neuralgia  of  the  thoracic  parietes     ....         433 

Of  magnetism  as  a  remedy  in  neuralgia  .  .  .  434 

Of  the  varieties  and  pathology  of  asthma     .  ,  .         446 

Of  the  treatment  of  asthma        .....  452 

Literature  of  asthma  .  .  .  .  .    ,     457 

Of  the  period  of  effusion  in  serous  inflammations  .  .  460 

Character  of  the  effused  fluid  at  different  periods  of  the  disease  462 
Of  the  mobility  of  the  effused  fluid  by  change  of  position         .  474 
Of  the  vibration  communicated  to  the  walls  of  the  chest  in 

speaking,  as  a  sign  of  pleurisy  (M.  L.)  .  .  .  478 

Of  the  physical  diagnostics  of  pleurisy  and  pneumonia        .         479 
Of  tenderness  of  the  exterior  of  the  chest  in  pleurisy    .  .  480 

Of  the  frequency  and  diagnosis  of  chronic  pleurisy  .         486 

Of  contraction  of  the  chest  after  pleurisy  .  .  .  499 

Of  diaphragmitis       ......         501 

Of  tartar  emetic  in  large  doses  in  pleurisy         .  .  .  505 

Of  the  operation  of  empyema  .  .  .         512 

Literature  of  pleurisy      ......  516 

Of  the  existence  of  idiopathic  hydrothorax  .  .         517 

Of  the  connection  between  hydrothorax  and  inflammation        .  520 
Of  the  general  symptoms  of  hydrothorax     .  .  .         521 

Of  the  treatment  of  hydrothorax  ....  523 

Literature  of  hydrothorax      .....         524 

Of  the  usual  origin  and  cause  of  pneumothorax  .  .  527 

Chemical  analysis  of  the  gas  in  pneumothorax         .  .         530 

Of  the  symptoms  of  pneumothorax        ....  534 

Relative  frequency  of  pneumothorax  on  both  sides  (M.  L.)         556 
Diagnostic  signs  of  pneumothorax  and  their  respective  value   .  557 
True  rythm  or  progressive  movements  of  the  different  parts  of 
the  heart  .  .  .  •  •  •  •         588 

Non-isochronism  of  the  ventricular  systole  and  arterial  pulse   .  591 
Critical  examination  of  the  opinions  of  authors  respecting  the 

order  and  causes  of  the  motions  and  sounds  of  the  heart       .  595 
Of  the  musical  bellows-sound  •  •  •         603 

Bellows-sound  produced  by  plethora;  by  bronchocele  (M.  L., 

&  Tr.) 607 

Origin,  causes,  and  indications  of  the  different  valvular  sounds    613 
Of  the  purring  thrill  and  its  relation  to  the  rasp  sound  (M.  L., 

&  Tr.) 617 

Peculiar  variety  of  intermitting  pulse  .  .  .         624 

Of  the  general  symptoms  of  disease  of  the  heart  .  .  631 

Literature  of  diseases  of  the  heart  in  general  .  .         632 


Xlvi  CONTENTS. 

Page 

Of  the  relation  of  gangrene  of  the  limbs  to  disease  of  the  heart  635 
Of  the  causes  of  diseases  of  the  heart  .  •  •         638 

Classification  of  the  varieties  of  hypertrophy  of  the  ventricles     642 
State  of  the  pulse  in  hypertrophy  of  the  left  ventricle  .         643 

State  of  the  cerebral  circulation  in  hypertrophy  of  the  left  ven- 
tricle .......         645 

State  of  the  complexion  in  hypertrophy  .  .  •  645 

Of  swelling  and  pulsation  of  the  jugular  veins  in  hypertrophy     646 
Relation  of  hypertrophy  of  the  right  ventricle  to  haemoptysis  .  647 
Of  the  causes  of  dilatation  of  the  ventricles  .  .         649 

Relation  of  dilatation  of  the  heart  to  enlarged  liver  and  ascites  651 
Relation  of  dilatation  of  the  heart  to  angina  pectoris,   head- 
aches, &c.  ......         651 

Dr.  Hope's  classification  of  hypertrophy  with  dilatation  .  654 

Literature  of  displacement  of  the  heart  .  .  .671 

Literature  of  malformation  of  the  heart  ....  674 

Of  suppurative  carditis         .....         675 

Literature  of  carditis  and  pericarditis     ....  678 

Of  apoplexy  of  the  heart  as  a  cause  of  rupture  of  the  heart 

(M.L.) 680 

Statistics  of  rupture  of  the  heart      ....         681 

.  682 

691 

.  691 

693 

.  694 

697 

.  706 

717 


Literature  of  rupture  of  the  heart 

Case  of  valvular  disease  of  the  heart 

Of  the  general  symptoms  of  valvular  disease     . 

Of  the  rasp-sound  and  the  purring-sound  (L.  M.) 

Of  the  particular  signs  of  valvular  disease 

Of  cardiac  asthma    .... 

Literature  of  polypus  of  the  heart 

Of  the  origin  of  valvular  excrescences 

Of  the  leather-creak  as  a  sign  of  pericarditis  {M.  L.)  .  .  731 

Dr.  Stokes's  diagnostics  of  pericarditis        .  .  .         731 

Of  the  treatment  of  pericarditis  ....  733 

Of  the  auscultatory  diagnostics  of  aneurism  of  the  aorta     .         746 
Of  the  macerating  treatment  of  Albertini  and  Valsalva,  in  aneu- 
rism of  the  aorta  .  ...         749 

Of  hydrocyome  acid  and  asparagus  in  organic  diseases  of  the 
heart  .......         750 

Of  digitalis  in  diseases  of  the  heart        ....  752 

Of  the  importance  of  removing  gastric  and  other  irritations  in 
diseases  of  the  heart  ......  753 

Of  the  nature,  varieties,  &c.  of  angina  pectoris       .  .         758 

Of  the  treatment  of  angina  pectoris       ....  761 

Literature  of  angina  pectoris  ....  762 

Value  of  auscultation  in  the  diagnosis  of  pregnancy      .  .  772 

Literature  of  auscultation     .....         780 

Literature  of  diseases  of  the  chest  in  general        .  .  .  782 


CONTENTS 


PRINCIPAL  NOTES  OF  M.  ANDRAL. 


Page. 
Of  the  mean  number  of  respirations  in  a  minute     .  .  .  .15 

Of  the  difference  in  the  intensity  of  the  murmur  of  respiration  at  different 

ages          .........  36 

Respiration  attended  by  two  sounds       .  .  .  .  .38 

Of  the  point  of  time  at  which  the  different  rhonchi  occur  during  the  act  of 

respiration            .             .                          .            .             .             .             .  62 

Ancient  and  modern  notions  of  catarrh         .  .  .  .  .69 

Of  the  power  of  the  gastric  juice  in  destroying  the  coats  of  the  stomach  71 
The  dyspnoea  occasioned  by  the  obliteration   of  one  of  the  bronchi  ex- 
plained   .........  72 

Of  the  danger  indicated  by  the  extension   of  the  different  rhonchi  in  the 

lungs              .........  76 

On  the  use  of  the  term  bronchitis  in  cases  of  chronic  mucous  catarrh  .  81 

Of  alterations  in  the  bronchi  in  chronic  pulmonary  catarrh                .             .  81 
Profuse   haemoptysis   uncommon  in   cases  of  simple   chronic   pulmonary 

1    catarrh     .........  82 

On  a  variety  of  asthma  accompanying  chronic  pituitous  catarrh      .             .  90 

On  the  use  of  bleeding  in  cases  of  suffocative  catarrh     ...  95 
On  the  variations  in  the  intensity  of  the  respiratory  sound  in  cases  of  dry 

catarrh           .........  98 

Of  the  rhonchi  occurring  in  cases  of  fever           ....  Ill 

On  the  causes  of  the  contraction  of  the  bronchi        ....  129 

Of  the  operation  of  tracheotomy  in  croup             ....  140 

Of  haemoptysis  as  connected  with  menstruation        ....  142 

On  the  influence  of  the  manufacture  of  gun  flints  in  producing  tubercles  150 
On  the  changes  which  the  vesicles  of  the  lungs  undergo  at   different  pe- 
riods of  life          ........  156 

Of  the  production  of  pulmonary  emphysema             ....  168 

Of  the  progress  and  cause  of  dyspnoea  which  depends  on   emphysema  of 

the  lungs              .                                       ......  169 

Of  the  cough  attending  pulmonary  emphysema         .                         .             .  170 
Of  organic  affections  of  the  heart,  and  of  the  dilatation  of  the  chest  result- 
ing from  pulmonary  emphysema             .....  171 

Of  the  symptoms  afforded  by  anscultation  in  cases  of  emphysema  of  the 

lungs               ....•••••  1<2 

Of  the  fatal  effects  of  limited  emphysema  occurring  suddenly  in  the  lungs  185 

Of  the  different  forms  of  oedema  of  the  lungs      ....  188 

Of  the  influence  of  elevated  regions  in  causing  hasmoptysis            .             .  205 

Of  the  treatment  of  pulmonary  haemoptysis         ....  206 

Of  deposits  of  pus  in  the  lungs  resulting  from  inflammation  of  the  veins  217 

Of  the  development  of  accidental  productions          ....  281 

Of  nervous  phthisis  and  venereal  phthisis            ....  283,  284 

Of  the  nature  and  seat  of  tubercle     .                         .             .             •             •  285 
Of  the  sputa  secreted  in  tuberculous  cavities       .            .             .  297 
Of  the  symptoms  attending  the  sudden  and  extensive  development  of  tu- 
bercles in  the  lungs               .......  301 

Of  the  simultaneous  existence  of  tubercles  in  different  organs  in  children 

and  adults            ...•••••  202 

Of  the  contractions  of  the  chest  in  cases  of  phthisis             .             .             •  305 
Of  the  origin  of  tubercles             ......  318— 3'20 


xlviii 


CONTENTS. 


Paije 
Of  the  frequency  of  pulmonary  phthisis  in  different  countries         .  .     342 

Of  mental  troubles  considered  as  causes  of  tubercles       .  .  •  348 

Of  the  frequency  of  phthisis  at  different  periods  of  life        .  •  •     352 

Of.  the  relative  frequency  of  phthisis  in  males  and  females         .  .  353 

Of  the  influence  of  different  occupations  on  the  production  of  phthisis  355 — 358 
Of  the  aid  furnished  by  percussion  and  auscultation  in  detecting  the  exis- 
tence of  tubercles  .......  358 — 360 

Of  the  cough  connected  with  tubercles  in  the  lungs  .  •  •     370 

Of  haemoptysis  connected  with  the  existence  of  tubercles  in  the  lungs  371 

Perspiration  not  a  constant  symptom  of  phthisis         ....     372 

Of  pains  in  the  chest  of  phthisical  patients  ....  374 

Pulmonary  phthisis  not  always  attended  by  expectoration    .  .  .     377 

Of  dyspnoea  as  a  symptom  of  phthisis        .....  379 

Of  a  rare  form  of  acute  phthisis  of  which  dyspnoea  is  the   predominating 

symptom    .  .  .  .  .  .  .  .  .'    385 

Of  the  laws  of  mortality  in  phthisis  .....  386 

Of  the  difficulty  attending  the  treatment  of  phthisis  .  .  .     397 

Of  the  composition  of  calcareous  concretions  found  in  the  lungs  .  406 

Of  the  connexion  of  calcareous  concretions  in  the  lungs  with  tubercles       .     410 
Of  the  source  of  the  black  or  melanotic  matter  found  in  the  lungs  .  417 

Of  encephaloid  productions  in  the  lungs  and  other  organs  .  .  424,425 

Of  dropsy  depending  on  cancer  of  the  liver  and  womb    .  .  .  430 

Of  thymic  asthma         ........     439 

Of  nervous  dyspnoea  or  asthma      ......  443 

Of  the  cure  of  symptomatic  dropsy      ......     523 

Of  the  most  common  species  of  pneumothorax     ....  530 

Of  the  granulations   formed  on   the  free  surface  of  the  serous   membranes 

not  identical  with  the  grey  granulations  found  in  the  lungs       .  .    562 

Of  enormous  encephaloid  masses  found  in  the  chest         .  .  .  565 

Of  diagnosis  of  the  diseases  of  the  organs  of  circulation  prior  to  the  discov- 
ery of  auscultation  .......     567 

Of  percussion  in  diseases  of  the  heart        .....  568 

Of  the  pulse  glass  and  its  merits  ......    577 

The  impulse  of  the  heart  sometimes  increased  by  general  debility  .  578 

Of  the  cause  of  the  impulse  or  shock  of  the  heart  and  its  effect  on  the  chest  578-580 
Of  the  isochronism  of  the  pulse  and  the  sounds  of  the  heart        .  .  580 

Of  all  the  theories  proposed  to  account  for  the  sounds  of  the  heart  583 — 586 

Of  the  weight  and  size  of  the  heart         .....   586 — 588 

Of  the  aberration  of  the  heart's  rythm  .....     593 

Of  the  bellows-sound  and  other  abnormal  sounds  of  the  heart    .  .    601,602 

Of  the  cause  of  the  bellows-sound  and  other  abnormal  sounds  of  the  heart  607-609 
Of  the  anormal  sounds  of  the  arteries  and  the  causes  of  them  .  .    610 — 613 

Of  the  cause  of  the  purring-thrill         ......     614 

Of  the  sounds  of  the  heart  as  heard  at  a  distance  .  .  .  619 

Of  the  causes  of  the  intermission  of  the  pulse  ....     623 

Of  the  connexion  between  the  force  of  the  arterial  pulsations   and  that  of 

the  heart  ........  626 

Haemoptysis  rare  in  cases  of  organic  affections  of  the  heart  .  .     630 

Of  the  cause  of  vomitings  in  cases  of  diseases  of  the  heart  .  .  630 

Diseases  of  the  heart  uncommon  among  phthisical  patients    .  .  .     637 

Of  the  influence  of  pericarditis   and  endo-carditis  in    the  development   of 

diseases  of  the  heart  .  .  .  .  .  .  640 

Of  the  modification  of  the  sounds  of  the  heart  in  hypertrophy  of  the  organ  664 
Of  the  change  in  the  form  of  the  chest  resulting  from  diseases  of  the  heart  664 
Of  the  dilatation  of  the  orifices  of  the  heart  .....     661 


Of  the  symptoms  of  softening  of  the  heart 

Of  the  nature  and  cause  of  softening  of  the  heart 

Of  inflammation  of  the  tissues  of  the  heart 

Of  deficiency  of  the  valves  of  the  heart 

Of  polypiform  concretions  developed  in  the  heart 

Of  the  effects  of  pus  on  coagulated  blood 

Of  endo-carditis,  its  symptoms  and  effects 

Of  bloodletting  in  cases  of  nervous  palpitations 


664 

-    666 

677 

.    694 

704,  705 

.    714 

715,  716 

■    764 


A  TREATISE 


ON 


DISEASES  OF  THE  CHEST,  &c. 


INTRODUCTION. 

Of  all  the  diseases  which  are  essentially  local,  those  of  the  tho- 
racic organs  are  unquestionably  the  most  frequent  ;*  While  in 
point  of  danger,  they  can  only  be  compared  with  organic  affec- 
tions of  the  brain.f  The  heart,  lungs,  and  brain,  constitute,  ac- 
cording to  the  happy  expression  of  Borden,  the  tripod  of  life; 
and  none  of  these  organs  can  sustain  any  considerable  or  exten- 
sive morbid  change,  without  the  greatest  danger.  The  delicacy 
of  their  organization  and  their  incessant  motion,  account  for  the 
frequency  and  severity  of  their  diseases.  In  no  other  texture  of 
the  animal  system  is  idiopathic  and  primary  inflammation  so  fre- 
quent a  source  of  severe  disorder  and  death,  as  in  the  lungs ; 
and  no  other  is  so  liable  to  become  the  seat  of  accidental  produc- 
tions of  every  kind,  more  especially  of  the  tubercles,  the  most 
common  of  all.J     The  heart,  although  of  a  less  delicate  texture, 

*  However  common  the  diseases  of  the  thoracic  organs  may  be,  it  would  be 
difficult  to  show  that  they  are  the  most  frequent  of  all  local  affections.  The 
stomach  and  the  uterus  are  as  often  the  seat  of  disease  as  the  lungs  or  heart. 

The  frequency  of  pulmonary  affections  in  particular,  cannot  be  thus  established 
as  a  general  fact:  climate  has  much  to  do  in  the  matter.  Laennec's  observation 
can  only  apply  to  countries  where  the  temperature  and  other  atmospheric  pecu- 
liarities are  the  same  with  those  of  Paris  and  London.  In  warm  countries  or 
climates,  diseases  of  the  respiratory  organs,  whether  acute  or  chronic,  are  rare, 
while  disorders  of  other  organs  become  more  frequent.  Thus  in  the  East 
Indies  inflammations  of  the  lungs,  and  tubercular  affections  of  these  organs,  are 
seldom  met  with  ;  while  on  the  other  hand,  inflammatory  affections  of  the  liver, 
terminating  more  or  less  rapidly  in  suppuration,  are  very  common.  All  medical 
writers  upon  the  diseases  of  India,  speak  of  numerous  cases  of  abscess  of  the 
liver,  a  lesion  very  rare  in  our  climate,  and  seldom  met  with  except  in  cases  of 
phlebitis  or  of  purulent  absorption. — inilral. 

t  In  all  organic  affections,  the  danger  is  nearly  equal :  whether  the  stomach, 
the  liver,  the  kidneys  or  the  uterus  be  the  organs  affected,  the  prognosis,  as  far 
as  relates  to  final  recovery,  is  as  unfavorable  as  that  of  organic  affections  of  the 
lungs,  heart  or  brain. — Jlndral. 

X  This  is  inaccurate  :  a  man  so  profoundly  versed  in  pathological  anatomy  as 
Laennec,  could  only  have  been  led  to  such  a  remark  by  a  strange  oversight.     If 
1 


A  INTRODUCTION. 

is  equally  obnoxious  to  morbid  changes.  Of  these,  it  is  true, 
some  are  only  of  rare  occurrence :  but  others  are  extremely  com- 
mon,— for  instance,  thickening  of  its  muscular  substance,  and 
dilatation  of  its  cavities. 

Diseases  of  the  chest,  in  respect  of  their  frequency  and  seve- 
rity, hold  also  the  first  rank  among  those  affections  which,  either 
as  complications  or  effects,  are  found  to  accompany  other  diseases 
of  a  general  nature.  Thus  in  idiopathic  fevers,  a  slight  degree 
of  peripneumony,  a  determination  of  blood  to  the  lungs,  or  a 
catarrh  occasioning  redness  and  thickening  of  the  internal  mem- 
brane of  the  bronchi  and  pouring  into  them  an  augmented  secre- 
tion of  mucus, — are  local  affections,  quite  as  constant  in  their 
occurrence  as  the  redness,  thickenings,  or  ulcerations  of  the  mu- 
cous membrane  of  the  intestines,  in  which  several  authors,  an- 
cient and  modern,  have  fancied  they  discovered  the  cause  of 
these  diseases.  It  may  even  be  asserted,  that  in  maladies  of 
every  sort,  whatever  be  their  seat,  death  scarcely  ever  occurs 
without  the  chest  becoming  affected  in  one  way  or  other ;  and 
that,  in  most  cases,  life  does  not  seem  in  peril  until  the  superven- 
tion of  a  congested  state  of  the  lungs,  serous  effusion  into  the 
pleura,  or  great  disorder  of  the  circulation.  The  brain  in  gene- 
ral becomes  affected  only  subsequently  to  these  changes ;  and 
frequently  remains  undisturbed  even  to  the  last  moment  of  life. 

However'  dangerous  diseases  of  the  chest  may  be,  they  are, 
nevertheless,  more  frequently  curable  than  any  other  severe  in- 
ternal affection.  For  this  double  reason  medical  men,  in  all 
ages,  have  been  desirous  of  obtaining  a  correct  diagnosis  of  them. 
Hitherto,  however,  their  efforts  have  been  attended  by  little 
success, — a  circumstance  which  must  necessarily  result  from 
their  having  confined  their  attention  to  the  observation  and  study 
of  the  deranged  functions  only.  From  the  continued  operation 
of  the  same  cause,  we  must  even  now  confess,  with  Baglivi,  that 
the  diagnosis  of  the  diseases  of  this  cavity  is  more  obscure  than 
that  of  those  of  any  other  internal  organ.  Diseases  of  the  brain, 
not  in  themselves  numerous,  are  distinguished,  for  the  most 
part,  by  constant  and  striking  symptoms  ;*  the  soft  and  yielding 

tubercles  invade  the  lungs  oftener  than  any  other  organ  we  cannot  say  the  same 
of  many  other  accidental  productions.  Schirrus  and  encephaloid  formations,  for 
example,  which  in  importance  occupy  the  same  rank  in  organic  disease  with 
tubercles,  are  seldom  developed  in  the  lungs,  while  other  organs  are  very 
frequently  the  seats  of  them. — Anil  ml. 

*  Laennec  here  is  not  sufficiently  attentive  to  the  diagnosis  of  the  diseases  of 
the  brain.  In  the  greater  part  of  these  cases,  it  is,  no  doubt,  easy  to  discover 
that  it  is  the  brain  which  is  affected ;  yet  there  is  often  a  difficulty  in  ascertain- 
ing whether  the  symptoms  indicating  an  affection  of  the  brain,  do  not  originate 
in  the  morbid  condition  of  some  other  organ. 

.  ,  In  studying  the  maladies  of  the  nervous  centres,  there  are,  however,  more 
important   problems  to  resolve,  than  the  above.     Having  ascertained  that  the 


INTRODUCTION.  3 

walls  of  the  abdomen  allow  us  to  examine,  through  the  medium 
of  touch,  the  organs  of  that  cavity,  and  thus  to  judge,  in  some 
measure,  of  their  size,  position,  and  degree  of  sensibility,  and 
also  of  the  extraneous  substances  that  may  be  formed  in  them. 
On  the  other  hand,  the  diseases  of  the  thoracic  viscera  are  very 
numerous  and  diversified,  and  yet  have  almost  all  the  same  class 
of  symptoms.  Of  these  the  most  common  and  prominent  are 
cough,  dyspnoea,  and,  in  some,  expectoration.  These,  of  course, 
vary  in  different  diseases  ;  but  their  variations  are  by  no  means 
of  that  determinate  kind  which  can  enable  us  to  consider  them 
as  certain  indications  of  known  variations  in  the  diseases.  The 
consequence  is,  that  the  most  skillful  physician  who  trusts  to  the 
pulse  and  general  symptoms,  is  often  deceived  in  regard  to  the 
most  common  and  best  known  complaints  of  this  cavity.  Nay, 
I  will  go  so  far  as  to  assert,  and  without  fear  of  contradiction 
from  those  who  have  been  long  accustomed  to  the  examination 
of  dead  bodies, — that  before  the  discovery  of  Avenbrugger,  one- 
half  of  the  acute  cases  of  peripneumony  and  pleurisy,  and  al- 
most all  the  chronic  pleurises,  were  mistaken  by  practitioners ; 

brain  is  diseased,  the  first  inquiry  should  be,  what  is  the  nature  of  the  alteration 
it  has  undergone  ?  the  second,  what  portion  of  the  brain  has  suffered  this  alter- 
ation ?  In  clearing  up  these  two  points  numerous  obstacles  occur,  some  of  which 
are,  in  the  present  state  of  the  science,  insurmountable.  If  we.  endeavor  to 
ascertain  the  nature  of  the  malady,  we  meet  with  a  serious  difficulty  in  the  cir- 
cumstance that  many  of  these  affections  exhibit  common  symptoms  by  which 
distinct  maladies  become  confounded,  without  offering  any  features  sufficiently 
marked  to  distinguish  one  from  another.  Thus,  notwithstanding  what  has  been 
said  on  this  point,  the  softening  of  the  brain  in  one  form  of  the  disease,  displays 
itself  by  symptoms  no  way  differing  from  those  produced  by  cerebral  hemorrhage. 
In  another  form,  it  gives  rise  to  functional  disorders  similar  to  those  which  are 
caused  by  an  accidental  production  developed  in  the  midst  of  the  cerebral  mass. 
There  are  also  cases  more  numerous  than  many  persons  imagine,  in  which,  not- 
withstanding the  patient  during  life,  may  have  exhibited  symptoms  like  those 
which  result  from  hemorrhage  or  softening  of  the  brain — yet  a  post-mortem 
examination  will  not  show  either  a  lesion  of  this  character,  or  any  other  lesion 
which  the  present  state  of  anatomical  science  is  able  to  bring  to  light.  Conse- 
quently in  diseases  of  the  brain,  functional  disorders  which  are  identical,  may 
be  found  to  arise  from  lesions  the  most  diverse  in  their  character,  or  exist  when 
no  lesion  can  be  discovered.  If,  therefore,  we  depend  upon  the  symptoms  to 
enable  us  to  point  out  the  precise  portion  of  the  brain  in  which  the  alteration 
exists,  we  shall  find  that  in  a  great  number  of  cases  our  diagnosis  will,  on  post- 
mortem examination,  be  found  incorrect.  Thus  in  spite  of  recent  assertions, 
we  cannot  affirm  that  special  symptoms  belong  to  lesions  of  the  anterior,  middle, 
or  posterior  lobes  of  the  brain.  Moreover  it  cannot  be  said  that  lesions  of  the 
cerebellum,  can  generally  be  distinguished  from  those  of  the  cerebrum,  by  the 
peculiarity  of  the  functional  disorders  consequent  upon  them. 

However  much,  therefore,  our  knowledge  of  the  pathology  of  the  brain  may 
have  been  advanced  by  recent  researches,  we  are  still  very  far  from  being  able 
to  determine,  in  a  great  number  of  instances,  the  precise  seat  and  degree  of  a) 
terations  in  this  organ.  In  this  double  relation,  the  pathology  of  the  thoracic  and 
abdominal  organs  is  infinitely  more  advanced ;  a  circumstance  doubtless  owing 
to  our  ability,  in  disorders  of  these  organs,  of  correcting  whatever  is  vague  and 
unsettled  in  the  symptoms  depending  upon  functional  derangement,  by  the 
more  positive  and  constant  signs  furnished  by  palpation,  percussion  and  auscul- 
tation.— Andral. 


INTRODUCTION. 


and  that,  in  such  instances  as  the  superior  tact  of  a  physician 
enabled  him  to  suspect  the  true  nature  of  the  disease,  his  convic- 
tion was  rarely  sufficiently  strong  to  prompt  and  justify  the  ap- 
plication of  very  powerful  remedies.  The  percussion  of  the 
chest,  according  to  the  method  of  the  ingenious  observer  just 
mentioned,  is  one  of  the  most  valuable  discoveries  ever  made  in 
medicine.  By  means  of  it,  several  diseases  which  had  hitherto 
been  cognisable  by  general  and  equivocal  signs  only,  are  brought 
within  the  immediate  sphere  of  our  perceptions,  and  their  diag- 
nosis, consequently,  rendered  both  more  easy  and  more  certain. 
It  is  not  to  be  concealed,  however,  that  this  mode  of  exploration 
is  very  incomplete.  Confined,  in  a  great  measure,  to  the  indica- 
tion of  fullness  or  emptiness,  it  is  only  applicable  to  a  limited 
number  of  organic  lesions  ;  it  does  not  enable  us  to  discriminate 
some  which  are  very  different  in  their  nature  or  seat ;  it  scarcely 
affords  any  indication  except  in  extreme  cases,  and  cannot  there- 
fore enable  us  to  detect,  or  even  to  suspect,  diseases  in  their  very 
commencement.  It  is  more  particularly  in  diseases  of  the  heart 
that  we  regret  the  insufficiency  of  this  method,  and  wish  for 
something  more  precise.  The  general  symptoms  of  disease  in 
this  organ  greatly  resemble  those  produced  by  many  nervous 
complaints,  and  by  the  diseases  of  other  organs.  The  application 
of  the  hand  affords  some  indications  as  to  the  extent,  strength, 
and  rythm  of  the  heart's  motions  ;  but  these  in  general  are  by 
no  means  distinct,  while,  in  cases  of  considerable  fatness  or  ana- 
sarca, they  become  very  obscure,  or  are  altogether  impercep- 
tible. Within  these  few  years  some  physicians  have,  in  those 
cases,  attempted  to  gain  further  information  by  the  application 
of  the  ear  to  the  cardiac  region.  In  this  way,  the  pulsations  of 
the  heart,  perceived  at  once  by  the  ear  and  touch,  become,  no 
doubt,  more  distinct.  But  even  this  method  comes  far  short  of 
what  might  be  expected  from  it.  Bayle  was  the  first  who  to  my 
knowledge  had  recourse  to  it,  at  the  time  when  we  were  attend- 
ing the  lectures  of  Corvisart.  This  great  man  himself  never 
used  it :  he  says  only  that  he  had  several  times  heard  the  pulsa- 
tion of  the  heart  in  listening  very  close  to  the  chest.*  We  shall 
afterwards  find  that  this  phenomenon  is  different  from  ausculta- 
tion, properly  so  called,  and  is  only  observable  in  some  particular 
cases.  But  neither  Bayle  nor  any  other  of  our  fellow  students 
who  with  myself  might,  in  imitation  of  him,  employ  this  imme- 
diate auscultation,  (of  which,  by  the  way,  the  first  notion  is  de- 
rived from  Hippocrates,)  obtained  any  other  result  from  it  than 
that  of  perceiving  more  distinctly  the  action  of  the  heart,  in  the 
cases  where  this  was  not  very  perceptible  to  the  touch .f     The 

*  Essai  sur  los  Maladies  du  Cceur.  3c.  Ed.  p.  396. 

t  The  practice  of  Immediate  Auscultation  is  noticed  by  M.   Double   in  the 


INTRODUCTION.  O 

reason  of  this  limited  application  will  be  stated  hereafter.  But, 
independently  of  its  deficiencies,  there  are  other  objections  to  its 
use  :  it  is  always  inconvenient  both  to  the  physician  and  patient ; 
in  the  case  of  females  it  is  not  only  indelicate  but  often  imprac- 
ticable ;  and  in  that  class  of  persons  found  in  hospitals  it  is  dis- 
gusting. For  these  various  reasons  this  measure  can  but  rarely 
be  had  recourse  to,  and  cannot  therefore  become  practically  use- 
second  volume  of  his  Semeiologic  Generale,  published  two  years  before  the  first 
edition  of  the  Treatise  of  Laennec.  Speaking  of  the  signs  furnished  by  respi- 
ration, and  of  the  sounds  produced  by  it  within  the  chest  in  disease,  he  says  that, 
with  the  view  of  hearing  them  more  distinctly,  "  we  must  apply  the  ear  closely 
to  every  point  of  all  its  aspects  ;  by  which  means  we  can  distinguish,  not  merely 
the  kind  and  degree  of  the  sound,  but  even  its  precise  site."  He  adds,  "  I  have 
frequently  derived  great  benefit  from  this  mode  of  investigation,  which  is  pecu- 
liar to  myself,  and  to  which  I  was  naturally  led  by  the  employment  of  the  like 
method  in  exploring  the  pulsation  of  the  heart."  Semeiol.  t.  ii.  p.  31.  Paris, 
1817. — Long  before  this  period,  indeed,  one  of  our  own  countrymen,  not  of  the 
medical  profession,  and  who,  in  all  probability,  was  unacquainted  with  the  writ- 
ings of  Hippocrates,  was  fully  aware  both  of  the  existence  and  great  importance 
of  internal  sounds  as  a  means  of  diagnosis,  and,  as  Dr.  Elliotson  well  observes, 
seems  almost  to  have  prophesied  the  stethoscope.  I  quote  the  more  striking 
parts  of  the  passage  as  extremely  curious  in  the  literary  history  of  auscultation. 
"  The  re  may  be  a  possibility,"  says  Hook,  "  of  discovering  the  internal  motions 
and  actions  of  bodies  by  the  sound  they  make.  Who  knows  but  that,  as  in  a 
watch  we  may  hear  the  beating  of  the  balance,  and  the  running  of  the  wheels, 
and  the  striking  of  the  hammers,  and  the  grating  of  the  teeth,  and  multitudes  of 
other  noises; — who  knows,  I  say,  but  that  it  may  be  possible  to  discover  the 
motions  of  the  internal  parts  of  bodies,  whether  animal,  vegetable,  or  mineral, 
by  the  sound  they  make;  that  one  may  discover  the  works  performed  in  the 
several  offices  and  shops  of  a  man's  body,  and  thereby  discover  what  instrument 
or  engine  is  out  of  order,  what  works  are  going  on  at  several  times,  and  lie  still 
at  others,  and  the  like." — "  I  have  this  encouragement  not  to  think  all  these 
things  utterly  impossible,  though  never  so  much  derided  by  the  generality  of 
men,  and  never  so  seemingly  mad,  foolish,  and  fantastic;  that,  as  the  thinking 
them  impossible  cannot  much  improve  my  knowledge,  so  the  believing  them 
possible  may,  perhaps,  be  an  occasion  for  taking  notice  of  such  things  as  another 
would  pass  by  without  regard,  as  useless.  And  somewhat  more  of  encourage- 
ment I  have  also  from  experience,  that  I  have  been  able  to  hear  very  plainly  the 
beating  of  a  man's  heart ;  and  it  is  common  to  hear  the  motion  of  the  wind  to  and 
fro  in  the  guts  and  other  small  vessels  :  the  stopping  in  the  lungs  is  easily  dis- 
covered by  the  wheezing,  the  stopping  of  the  head  by  the  humming  and  whist- 
ling noises,  the  slipping  to  and  fro  of  the  joints,  in  many  cases  by  crackling  and 
the  like.  As  to  the  working  or  motion  of  the  parts  one  amongst  another,  methinks 
I  could  receive  encouragement  from  hearing  the  hissing  noise  made  by  a  corro- 
sive menstruum  in  its  operation,  the  noise  of  fire  in  dissolving,  of  water  in  boil- 
ing, of  the  parts  of  a  bell  after  that  its  motion  is  grown  quite  invisible  as  to  the 
eye ;  for  to  me- these  motions  and  the  other  seem  only  to  differ  secundum  magis 
ct  minus,  and  so  to  their  becoming  sensible,  they  require  either  that  their  motions 
be  increased,  or  that  the  organ  be  made  more  nice  and  powerful  to  sensate  and 
distinguish  them  [to  try  the  contrivance  about  an  artificial  tympanum]  as  they 
are  ;  for  the  doing  of  both  which  I  think  it  is  not  impossible  but  that  in  many 
cases  there  may  be  helps  found,  some  of  which  I  may,  as  opportunity  is  offered, 
make  trial  of,  which,  if  successful  and  useful,  I  shall  not  conceal."  (The  Post- 
humous Works  of  Robert  Hook,  M.D.  p.  39,  40.  Lond.  1705,  folio.) 

There  is  no  reason  to  believe  that  Laennec  was  acquainted  with  these  opin- 
ions of  the  English  philosopher;  nor  if  he  had,  would  this  knowledge,  anymore 
than  that  which  he  derived  from  the  writings  of  Hippocrates,  have  greatly  de- 
tracted from  his  merits  as  the  discoverer  of  mediate  auscultation,  and  the  inventor 
of  the  stethoscope. —  Transi. 


INTRODUCTION. 


ful ;  since  it  is  only  by  numerous  observations  and  the  compa- 
rison of  numerous  facts  of  the  same  kind,  that  we  can  ever,  in 
medicine,  separate  the  truth  from  the  errors  which  are  constantly 
derived  from  the  inexperience  of  the  observer,  from  the  varying 
fitness  of  his  perceptive  powers,  the  illusions  of  his  senses,  and 
the  inherent  difficulties  of  the  method  of  exploration  which 
he  employs.  Observations  made  after  long  intervals  can  never 
overcome  difficulties  of  this  kind.  Nevertheless,  I  have  been  in 
the  habit  of  using  this  method  for  a  long  time,  in  obscure  cases, 
and  where  it  was  practicable ;  and  it  was  the  employment  of  it 
which  led  me  to  the  discovery  of  one  much  better. 

In  1816,  I  was  consulted  by  a  young  woman  laboring  under 
general  symptoms  of  diseased  heart,  and  in  whose  case  percussion 
and  the  application  of  the  hand  were  of  little  avail  on  account  of 
the  great  degree  of  fatness.  The  other  method  just  mentioned 
being  rendered  inadmissible  by  the  age  and  sex  of  the  patient,  I 
happened  to  recollect  a  simple  and  well-known  fact  in  acoustics, 
and  fancied  it  might  be  turned  to  some  use  on  the  present  occa- 
sion. The  fact  I  allude  to  is  the  great  distinctness  with  which  we 
hear  the  scratch  of  a  pin  at  one  end  of  a  piece  of  wood,  on  ap- 
plying our  ear  to  the  other.  Immediately,  on  this  suggestion,  I 
rolled  a  quire  of  paper  into  a  kind  of  cylinder  and  applied  one 
end  of  it  to  the  region  of  the  heart  and  the  other  to  my  ear,  and 
was  not  a  little  surprised  and  pleased,  to  find  that  I  could  there- 
by perceive  the  action  of  the  heart  in  a  manner  much  more  clear 
and  distinct  than  I  had  ever  been  able  to  do  by  the  immediate 
application  of  the  ear.  From  this  moment  I  imagined  that  the 
circumstance  might  furnish  means  for  enabling  us  to  ascertain  the 
character,  not  only  of  the  action  of  the  heart,  but  of  every  spe- 
cies of  sound  produced  by  the  motion  of  all  the  thoracic  viscera, 
and,  consequently,  for  the  exploration  of  the  respiration,  the 
voice,  the  rhonchus,  and  perhaps  even  the  fluctuation  of  fluid 
extravasated  in  the  pleura  or  the  pericardium.  With  this  con- 
viction, I  forthwith  commenced  at  the  Hospital  Necker  a  series  of 
observations  from  which  I  have  been  able  to  deduce  a  set  of  new 
signs  of  diseases  of  the  chest,  for  the  most  part  certain,  simple, 
and  prominent,  and  calculated,  perhaps,  to  render  the  diagnosis 
of  the  diseases  of  the  lungs,  heart,  and  pleura,  as  decided  and 
circumstantial,  as  the  indications  furnished  to  the  surgeon  by  the 
introduction  of  the  finger  or  sound,  in  the  complaints  wherein 
these  are  used. 

The  following  work,  which  contains  the  result  of  these  obser- 
vations, I  shall  divide  into  three  Parts.  In  the  First  I  shall  de- 
tail the  various  methods  of  exploration  by  which  we  obtain  a 
knowledge  of  the  diseases  of  the  chest ;  the  Second  will  contain 
an  account  of  the  diseases  of  the  Bronchi,  Lungs,  and  Pleura ;  the 
Third,  of  the  diseases  of  the  Heart  and  its  appendages. 


INTRODUCTION.  7 

But  before  proceeding  with  my  subject,  it  may  be  well  to  say 
something  on  the  attempts  I  have  made  to  perfect  my  instru- 
ment of  exploration,  both  as  to  its  materials  and  shape,  in  order 
that  others,  who  may  entertain  a  like  design,  may  follow  a  dif- 
ferent route. 

The  first  instrument  which  I  used  was  a  cylinder  of  paper, 
formed  of  three  quires,  compactly  rolled  together,  and  kept  in 
shape  by  paste.  The  longitudinal  aperture  which  is  always  left 
in  the  centre  of  paper  thus  rolled,  led  accidentally  in  my  hands 
to  an  important  discovery.  This  aperture  is  essential  to  the  ex- 
ploration of  the  voice.  A  cylinder  without  any  aperture  is  best 
for  the  exploration  of  the  heart:  the  same  kind  of  instrument 
will  indeed  suffice  for  the  respiration  and  rhonchus  ;  but  both 
these  are  more  distinctly  perceived  by  means  of  a  cylinder  which 
is  perforated  throughout,  and  excavated  into  somewhat  of  a 
funnel  shape,  at  one  of  its  extremities,  to  the  depth  of  an  inch 
and  a  half.  The  most  dense  bodies  do  not,  as  might  have  been 
expected  from  analogy,  furnish  the  best  materials  for  these  in- 
struments. Glass  and  metals,  exclusively  of  their  weight  and 
the  sensation  of  cold  occasioned  by  their  application  in  winter, 
convey  the  sound  less  distinctly  than  bodies  of  inferior  density. 
Upon  making  this  observation,  which  at  once  surprised  me,  I 
wished  to  give  a  trial  to  materials  of  the  least  possible  density, 
and,  accordingly,  caused  to  be  constructed  a  cylinder  of  gold- 
beater's skin,  inflated  with  air,  and  having  the  central  aperture 
formed  of  pasteboard.  This  instrument  I  found  to  be  inferior  to 
all  the  others,  as  well  from  its  communicating  the  sounds  of  the 
thoracic  organs  more  imperfectly,  as  from  its  giving  rise  to 
foreign  sounds,  from  the  contact  of  the  hand,  &c. 

Bodies  of  a  moderate  density,  such  as  paper,  the  lighter  kinds 
of  wood,  or  Indian  cane,  are  those  which  I  always  found  prefer- 
able to  others.  This  result  is  perhaps  in  opposition  to  an  axiom 
in  physics ;  it  has,  nevertheless,  appeared  to  me  one  which  is  in- 
variable. In  consequence  of  these  various  experiments  I  now 
employ  a  cylinder  of  wood,  an  inch  and  a  half  in  diameter,  and 
a  foot  long,  perforated  longitudinally  by  a  bore  three  lines  wide, 
and  hollowed  out  into  a  funnel-shape,  to  the  depth  of  an  inch 
and  a  half  at  one  of  its  extremities.  It  is  divided  into  two 
portions,  partly  for  the  convenience  of  carriage,  and  partly  to 
permit  its  being  used  of  half  the  usual  length.  The  instrument 
in  this  form — that  is,  with  the  funnel-shaped  extremity, — is  used 
in  exploring  the  respiration  and  rhonchus :  when  applied  to  the  ex- 
ploration of  the  heart  and  the  voice,  it  is  converted  into  a  simple 
tube,  with  thick  sides,  by  inserting  into  its  excavated  extremity 
a  stopper  or  plug  traversed  by  a  small  aperture,  and  accurately 
adjusted  to  the  excavation.    This  instrument  I  have  denomi- 


8 


INTRODUCTION. 


nated  the  Stethoscope*  The  dimensions  mentioned  are  not  a 
matter  of  indifference.  A  greater  diameter  renders  its  exact  ap- 
plication to  certain  parts  of  the  chest,  impracticable  ;  greater 
length  renders  its  retention  in  exact  apposition  more  difficult, 
and  when  shorter,  it  is  not  so  easy  to  apply  it  to  the  axilla,  while 
it  exposes  the  physician  too  closely  to  the  patient's  breath,  and, 
besides,  frequently  obliges  him  to  assume  an  inconvenient  pos- 
ture,— a  thing  above  all  others  to  be  avoided,  if  we  wish  to  ob- 
serve accurately.  The  only  case  in  which  a  shorter  instrument 
is  useful,  is  where  the  patient  is  seated  in  bed  or  on  a  chair,  the 
head  or  back  of  which  is  close  to  him  :  then  it  may  be  more  con- 
venient to  employ  the  half-length  instrument.! 

In  speaking  of  the  different  modes  of  exploration,  I  shall  no- 
tice the  particular  positions  of  the  patient,  and  also  of  the  phy- 
sician, most  favorable  to  correct  observation.  At  present  I 
shall  only  observe  that,  on  all  occasions,  the  cylinder  should  be 
held  in  the  manner  of  a  pen,  and  that  the  hand  of  the  observer 
should  be  placed  very  close  to  the  body  of  the  patient  to  insure 
the  correct  application  of  the  instrument. 

The  end  of  the  instrument  which  is  applied  to  the  patient, — 
that,  namely,  which  contains  the  stopper  or  plug, — ought  to  be 
slightly  concave,  to  insure  its  greater  stability  in  application  ; 
and  when  there  is  much  emaciation,  it  is  sometimes,  though 
rarely,  necessary  to  insert  between  the  ribs  a  piece  of  lint  or 
cotton  covered  with  cloth,  on  which  the  instrument  is  to  be 
placed,  as,  otherwise,  the  results  might  be  affected  by  its  imper- 
fect application. 

Some  of  the  indications  afforded  by  mediate  auscultation  are 

*  From  aTrjdos,  pectus,  and  ckokIu,  Explore 

t  The  stethoscope  has  undergone  various  modifications  of  form  since  the  time 
of Laennec,  but  I  am  of  opinion  that  the  one  last  used  and  recommended  by  him 
is  still  the  best,— with  this  only  alteration,  of  having  the  stopper  made  conical 
in  place  of  being  rounded.  In  the  modification  of  the  stethoscope,  now  very 
commonly  used  and  originally  introduced  by  M.  Piorry,  too  much  has  been  sac- 
rificed to  portability  and  elegance.  It  is,  as  is  well  stated  by  Dr.  Williams  (Oyc 
of  Pract.  Med.  vol.  iv.)  faulty  in  having  the  conducting  power  of  the  wood  im- 
peded by  screws  and  a  thick  cap  of  ivory  ;  besides  which  the  excavated  end  is 
generally  very  ill  fitted.  The  following  observations  by  the  same  author  are 
very  just  and  deserving  the  attention  of  the  young  auscultator  :—  "  The  general 
excellence  of  this  instrument  will  depend  on  the  smoothness  and  true  turning  of 
the  interior,  and  the  perfect  adaptation  of  the  stopper  to  the  cavity  but  to°be 
fully  available  to  the  auscultator,  the  auricular  end  should  be  made  wide  or  nar- 
row, flat  or  concave,  to  fit  comfortably  to  his  ear.  Generally  it  will  be  found 
useful  to  make  this  end  slightly  concave,  and  somewhat  wider  by  a  ferule  of 
ivory  or  ebony,  than  the  general  diameter  of  the  instrument,  or  this  width  mav 
be  formed  in  the  wood  itself.  A  beginner  should  not  choose  a  stethoscope  Ins 
tily,  but  when  one  is  found  exactly  to  fit  the  ear,  a  more  perfect  tact  will  be  ac 
quired  by  keeping  to  the  same  instrument  than  by  using  a  variety  "  Cvc  of 
Pr.  Med.  vol.  iv.  Art.  Stethoscope—The  flexible  caoutchouc  tube  terminating  in 
a  small  ivory  funnel,  now  in  common  use  by  deaf  persons,  is  employed  by  somp 
auscultators,  and  in  some  respects  answers  the  purpose  well  enough  •  but  it  is  in 
others  decidedly  inferior  to  the  solid  instrument.  (See  Plate  at  the  end  )—Transl 


INTRODUCTION. 


very  easily  acquired,  so  that  it  is  sufficient  to  have  heard  them 
once  to  recognise  them  ever  after  ;  such  are  those  which  denote 
ulcers  in  the  lungs,  hypertrophy  of  the  heart  when  existing  in  a 
great  degree,  fistulous  communication  between  the  bronchi  and 
cavity  of  the  pleura,  &c.  There  are  others,  however,  which  re- 
quire much  study  and  practice  for  their  effectual  acquisition. 

The  use  of  this  new  method  must  not  make  us  forget  that  of 
Avenbrugger ;  on  the  contrary,  the  latter  acquires  quite  a  fresh 
degree  of  value  through  the  simultaneous  employment  of  the 
former,  and  becomes  applicable  in  many  cases,  wherein  its  soli- 
tary application  is  either  useless  or  hurtful.  It  is  by  this  com- 
bination of  the  two  methods  that  we  obtain  certain  indications 
of  emphysema  of  the  lungs,  pneumo-thorax,  and  of  the  existence 
of  liquid  extravasations  in  the  cavity  of  the  pleura.  The  same 
remark  may  be  extended  to  some  other  means,  of  more  partial 
application,  such,  for  example,  as  the  Hippocratic  succession, 
the  mensuration  of  the  thorax,  and  immediate  auscultation  ;  all 
of  which  methods,  often  useless  in  themselves,  become  of  great 
value  when  combined  with  the  results  procured  through  the  me- 
dium of  the  stethoscope. 

In  conclusion,  I  would  beg  to  observe,  that  it  is  only  in  an 
hospital  that  we  can  acquire,  completely  and  certainly,  the  prac- 
tice of  this  new  art  of  observation  ;  inasmuch  as  it  is  necessary 
to  have  occasionally  verified,  by  examination  after  death,  the  di- 
agnostics established  by  means  of  the  cylinder,  in  order  that  we 
may  acquire  confidence  in  the  instrument  and  in  our  own  obser- 
vation, and  that  we  way  be  convinced,  by  ocular  demonstration, 
of  the  correctness  of  the  indications  obtained.  It  will  be  suffi- 
cient, however,  to  study  any  one  disease  in  two  or  three  subjects, 
to  enable  us  to  recognise  it  with  certainty  ;  and  the  diseases  of 
the  lungs  and  heart  are  so  common,  that  a  very  brief  attendance 
on  an  hospital  will  put  it  in  the  power  of  any  one  to  obtain  all 
the  knowledge  necessary  for  his  guidance  in  this  important  class 
of  affections. 

It  would  no  doubt  be  expecting  too  much  of  physicians  ac- 
tively engaged  in  private  practice,  to  devote  much  time  to  the 
acquisition  of  this  knowledge  in  an  hospital;  but  they  may 
readily  and  compend  ously  obtain  the  necessary  opportunities 
through  the  kindness  of  friends  attached  to  these  establishments, 
who  can  make  them  acquainted  with  rare  or  interesting  cases  as 
they  occur.  In  this  way  there  is  no  physician  who  may  not,  in 
a  very  little  time,  learn  to  recognise  with  certainty  not  only  the 
cases  above  mentioned,  but  peripneumony,  pleurisy,  latent  ca- 
tarrhs, and  even  the  very  rudiments  of  these  affections  ;  and  this 
last-mentioned  circumstance  is  unquestionably  the  chief  practical 
benefit  of  auscultation,  inasmuch  as  these  diseases  are  the  more 
easily  cured,  according  as  they  are  subjected  to  early  treatment. 
2 


PART   FIRST. 

OF  THE  EXPLORATION  OF  THE  CHEST. 


CHAPTER  I. 


OF    THE    MORE    ANCIENT    METHODS. 

In  every  age  physicians  have  felt  the  insufficiency  of  those 
equivocal  symptoms,  deduced  from  the  general  condition  of  the 
patient  and  the  disturbance  of  the  functions,  to  make  known  in- 
ternal diseases,  and  have  accordingly  endeavored  to  discover 
physical  signs  which  might  be  immediately  cognizable  by  the 
senses.  It  is  with  this  view  that  almost  all  the  methods  of  ex- 
ploration used  in  surgery  have  been,  at  different  times,  applied  to 
the  study  of  diseases  of  the  chest ;  such  as  examination  by  the 
hand,  inspection  of  the  shape  and  motions  of  the  thorax,  mensu- 
ration, succession,  and  finally,  immediate  auscultation.  But 
owing  to  the  infrequency  of  the  instances  wherein  these  methods 
are  productive  of  any  useful  result,  the  inconvenience  and  fatigue 
— both  to  the  patient  and  physician — of  some  of  them,  and,  more 
especially,  the  very  little  benefit  hitherto  derived  from  them,  they 
had  all  fallen  into  such  disuse  as,  a  few  years  ago,  to  be  almost 
unknown  to  practitioners.  I  think  it  however  necessary,  in  this 
place,  to  examine  their  respective  value,  and  shall  add  to  thos6 
already  named,  some  of  more  modern  origin. 

Sect.  I.  Manual  examination  of  the  exterior  of  the  chest. 

The  physical  structure  of  the  chest  prevents  our  obtaining 
any  accurate  information  respecting  the  condition  of  the  organs 
contained  in  it,  by  the  act  of  touching  or  handling  it  externally. 
Fluctuation  in  the  intercostal  spaces,  reckoned  by  some  authors 
among  the  signs  of  fluids  collected  in  the  pleura  or  pericardium, 
can  only  be  observed  in  cases  where  the  fluids  have  penetrated 
the  intercostal  muscles  and  become  extravasated  beneath  the 
skin,  or  in   the  still  rarer  instance  where   the  intercostal   spaces 


12  EXPLORATION    OF    THE    CHEST. 

are  rendered  prominent  by  the  pressure  of  the  fluid  within  the 
chest. 

The  simple  application  of  the  hand  would  seem  to  furnish 
some  signs  of  greater  utility  ;  for  *when  a  person  in  health  speaks 
or  sings,  his  voice  excites  in  the  whole  walls  of  the  thorax  a  sort 
of  vibration,  which  is  easily  perceived  on  applying  the  hand  to 
the  chest.  This  phenomenon  is  no  longer  observable,  when, 
through  disease,  the  lungs  have  ceased  to  be  permeable  to  the 
air,  or  are  removed  from  the  walls  of  the  chest  by  an  effused 
fluid.  This  sign  is,  however,  of  inferior  value,  since  a  great 
many  causes  occasion  varieties  in  the  intensity  of  the  vibration, 
or  completely  destroy  iU  For  instance,  it  is  little  sensible  in 
fat  persons,  in  those  whose  integuments  are  rather  flaccid,  and 
in  those  who  have  a  sharp  and  weak  voice.  Anasarca  of  the  chest 
completely  destroys  it,  even  when  the  lungs  are  quite  sound. 
In  any  case  it  is  only  very  perceptible  at  the  anterior  and  supe- 
rior part  of  the  chest,  on  the  sides,  and  in  the  middle  of  the 
back.  From  these  and  other  causes  we  can  derive  little  prac- 
tical benefit  from  attending  to  this  particular  circumstance.  We 
can  only  presume  that  that  portion  of  the  lungs  where  it  exists 
is  permeable  to  the  air ;  but  are  not  justified  in  drawing  any  con- 
clusions from  its  absence. 

Notwithstanding  the  ineflicacy  of  this  method,  I  have  fre- 
quency employed  it  in  practice,  and  the  following  are  the  results 
obtained: — 1.  In  cases  of  abscess  of  the  lungs  communicating 
with  the  cellular  substance  of  the  exterior  of  the  chest,  I  have 
sometimes  perceived  a  sensation  indicative  of  the  passage  of  the 
air  through  the  fluid.  2.  In  cases  of  extensive  tuberculous  ex- 
cavations very  near  the  surface  of  the  lungs,  and  when  these 
were  also  attached  to  the  costal  pleura,  I  have  sometimes  per- 
ceived a  distinct  guggling  on  the  application  of  very  gentle  per- 
cussion or  by  merely  pressing  or  touching  the  part.*  3.  In  suf- 
focative catarrh,  or  the  rattles  of  dying  persons,  when  very 
strong,  a  similar  guggling  is  perceived.  4.  I  believe  that  a  si- 
milar result  is  produced  by  the  effusion  of  the  pus  of  an  abscess 
of  the  lungs,  or  of  the  softened  matter  of  a  tubercle,  into  the 
pleura,  in  those  cases  where  the  pulmonary  and  costal  pleura  are 
intimately  united  by  previous  disease.  5.  In  certain  subjects,  the 
hand  is  sensible  of  a  vibration,  resembling  that  of  a  fiddle-string 
when  touched,  recurring  after  long  intervals,  and  only  momen- 
tarily. This  phenomenon,  which  is  of  slight  importance,  and 
may  have  place  even  in  a  trifling  catarrh,  is  occasioned  by  the 
contraction  of  some  bronchial  ramification    near  the  surface  of 

*  The  same  circumstance  has  been  observed  by  Andral,  and  is  distinctly  stated 
in  the  third  volume  of  his  Clinique  Medicale,  p.  66.  It  will  be  more  particu- 
larly noticed  when  treating  of  the  diagnosis  of  Phthisis.— Transl. 


EXAMINATION    BY    THE    HAND.  13 

the  lungs,  as  is  proved  by  the  employment  of  the  stethoscope. 
6.  Sometimes  in  cases  of  emphysema  of  the  lungs,  particularly 
the  interlobular  emphysema,  a  species  of  dry  crepitation  is  felt 
by  the  hand.  7.  Sometimes  also  we  can  perceive  the  fluctuation 
which  takes  place  in  a  very  large  tuberculous  excavation,  or 
where  there  exists  an  effusion  of  air  and  fluid  in  the  pleura  at 
the  same  time,  on  the  patient  moving  the  chest  quickly :  in  this 
case,  however,  we  hear  the  fluctuation  still  more  distinctly. 

From  all  this  it  may  be  concluded  that  the  application  of  the 
hand  to  the  walls  of  the  chest,  is  of  very  inferior  value  as  a  means 
of  diagnosis  in  diseases  of  the  lungs  and  pleura,  and  that  even 
where  its  indications  are  of  any  value,  they  are  in  some  measure 
superfluous,  inasmuch  as  the  stethoscope  furnishes  us  with  others 
which  are  more  constant  and  certain.* 

The  application  of  the  hand  to  the  region  of  the  heart  was,  for 
a  long  time,  the  chief  means  employed  by  the  ancient  physicians 
to  judge  of  the  strength,  weakness,  or  other  characters  of  the 
pulse ;  but  the  indistinctness  of  the  sensations  communicated 
generally,  and  the  impossibility  of  perceiving  at  all  the  heart's 
action  in  many  cases,  have  justly  given  the  preference  to  the  ex- 
amination of  the  radial  artery.  Similar  obstacles  prevent  us  from 
deriving  any  benefit  from  this  mode  of  exploration  in  most  dis- 
eases of  the  heart.  A  very  marked  pulsation  frequently  indi- 
cates nothing  more  than  thinness  of  the  thoracic  parietes,  or  a 
state  of  mere  nervous  agitation ;  while,  on  the  contrary,  there 
sometimes  exists  no  perceptible  pulsation  even  in  cases  of  hyper- 

*  There  are  only  a  few  circumstances  relating  to  the  physical  condition  of  the 
chest  which  cannot  be  ascertained  without  the  direct  application  of  the  hand. 
Of  this  kind  is  soreness  or  tenderness  of  the  surface.  Much  tenderness  of  the 
surface  of  the  chest  on  simple  touch  usually  indicates  an  affection  of  the  exter- 
nal parts,  either  of  the  skin  or  muscles,  as  in  the  rheumatic  affection  termed  pleu- 
rodijne.  It  is,  however,  sometimes  produced  by  internal  diseases,  as  when  a 
collection  of  pus  in  the  pleura  is  making  its  way  outwards  by  perforation  of  an 
intercostal  space.  When,  however,  considerable  pressure  is  made  in  the  inter- 
costal spaces,  pain  is  very  frequently  experienced  in  pleuritic  affections,  more 
particularly  of  a  chronic  kind.  In  chronic  pneumonia  also,  and  in  phthisis, 
when  the  lungs,  as  frequently  happens,  are  adherent  to  the  costal  pleura,  the 
same  effect  is  frequently  observed ;  and  in  cases  of  this  kind  I  have  often  found 
inuch  uneasiness  produced  by  even  the  gentlest  percussion,  more  particularly  if 
made  without  the  pleximeter. 

A  preternatural  degree  of  temperature  of  any  part  of  the  surface  of  the  body 
has  been  always  considered  indicative  of  disease  of  the  particular  part,  or  of  the 
tissues  or  organs  which  lie  beneath  it.  The  same  rule  is,  no  doubt,  equally  ap- 
plicable to  the  diseases  of  the  chest ;  but  although  the  fact  may  be  so,  it  is  inter- 
esting more  as  a  pathological  phenomenon  than  as  a  means  of  diagnosis,  as  it 
scarcely  ever  exists  where  we  are  not  provided  with  more  certain  indications. 

Manual  examination  discovers  the  presence  and  degree  of  muscular  robust- 
ness, obesity,  or  emaciation,  also  oedema,  emphysema,  &c.  with  much  greater 
certainty  and  accuracy  than  mere  inspection  :  it  also  enables  us  to  judge  of  the 
natural  degree  of  thickness  of  the  thoracic  parietes,  a  circumstance  sometimes 
of  considerable  importance  in  appreciating  the  value  of  other  signs  derived  from 
different  methods  of  physical  exploration. —  Transl. 


14  EXPLORATION    OF    THE    CHEST. 

trophy,  or  great  dilatation  of  the  organ.  There  is  only  one  sign 
of  some  value  obtained  by  the  application  of  the  hand, — I  mean 
the  thrilling  sensation  analogous  to  the  purring  of  a  cat,  which  I 
shall  have  occasion  to  notice  hereafter. 

Sect.  II.  Inspection  of  the  exterior  of  the  chest,  and  mensuration. 

The  inspection  of  the  naked  chest  enables  us  to  perceive  any 
alteration  in  its  shape,  and  to  judge,  at  least  to  a  certain  extent, 
of  the  changes  which  have  taken  place  in  the  motions  of  the  or- 
gans it  contains.  It  makes  us  acquainted  with  the  alterations 
produced  by  rickets,  and  also  with  the  important  fact  of  dilata- 
tion of  the  chest  in  cases  of  extravasation  of  the  fluids  within  it, 
and  of  its  contraction  in  ulterior  stages  of  some  of  the  same  dis- 
eases which  occasion  its  dilatation.  It  enables  us  to  detect,  in 
certain  cases,  aneurisms  of  the  aorta  in  their  latter  stages. 

Mensuration,  by  means  of  a  cord  or  ribbon,  of  the  two  sides 
of  the  chest,  for  the  purpose  of  ascertaining  their  relative  size, 
has  never  afforded  me  any  very  useful  results.  The  difference 
of  half  an  inch  in  the  semi-circumference  is  very  perceptible  to 
the  eye  :  and  when  the  difference  is  less  than  this,  we  cannot  de- 
pend so  entirely  on  the  accuracy  of  our  admeasurement,  as  to 
feel  more  confidence  in  their  results  than  in  those  derived  from 
simple  inspection.* 

*  Andral's  opinion  differs  somewhat  from  our  author's  in  this  point.  He  says 
that  when  one  side  exceeds  the  other  by  rive  or  six  lines,  the  difference  is  very 
perceptible  to  the  eye,  but  adds,  that  mistakes  are  very  likely  to  be  made  in 
this  respect,  and  advises  mensuration  always  to  be  had  recourse  to. — Op.  Cit. 
Tom.  ii.  565. — I  agree  with  Andral  in  considering  mensuration  as  of  more  prac- 
tical value  than  our  author  is  disposed  to  admit.  Many  persons  differ  respecting 
extent  as  measured  by  the  eye  ;  actual  physical  results  cannot  be  called  in  ques- 
tion. As  the  contraction  or  dilatation  may  be  in  both  the  transverse  and  verti- 
cal directions,  it  is  necesssry,  if  we  wish  to  be  extremely  precise,  to  make  two 
admeasurements,  one  from  the  spine  to  the  sternum,  the  other  from  the  top  of 
the  shoulder  to  the  lowest  rib.  In  general,  however,  the  transverse  admeasure- 
ment is  all  that  is  requisite.  In  measuring  the  two  sides,  we  must  be  careful  to 
apply  our  tapes  in  a  precisely  similar  manner  to  each  side.  In  ascertaining  the 
transverse  extent,  we  first  make  our  measurements  after  a  complete  expiration, 
and  then  after  a  full  inspiration.  It  will  thus  frequently  be  seen  that,  although 
little  or  no  difference  is  found  between  the  two  sides  in  the  former  case,  it  is 
very  considerable  in  the  latter, — the  chest  on  the  diseased  side  not  at  all  ex- 
panding during  inspiration,  and  probably  expanding  even  more  than  in  the  state 
of  health  on  the  sound  side.  This  effect  is  rendered  particularly  striking  by 
fixing  the  middle  of  the  piece  of  tape  on  the  spine,  and  allowing  the  two  ends 
to  rest  somewhat  loosely  on  the  sternum,  so  as  to  be  moved  by  the  motions  of 
the  chest :  on  the  patient  taking  a  deep  breath,  the  end  on  the  sound  side  is  seen 
gradually  to  recede  from  the  sternum,  while  that  on  the  diseased  side  eitlier  re- 
mains stationary,  or  recedes  to  a  very  small  extent.  In  cases  of  contracted 
chest  succeeding  acute  pleurisy,  in  which  a  cure  had  been  effected,  it  is  inte- 
resting to  watch  month  by  month,  the  gradual  expansion  of  the  contracted  side. 
In  such  instances  we  have  been  accustomed  to  supply  the  patient  with  a  marked 
piece  of  tape,  and  have  been  gratified  to  prove  by  this  means,  at  certain  inter- 
vals, the  progressive  return  of  the  chest  to  its  natural  size.— Transl. 


INSPECTION.  15 

The  inspection  of  the  movements  of  the  thorax  has  always  been 
considered  as  affording  information  as  to  the  degree  of  perfection 
or  imperfection  of  respiration.  It  has  been  particularly  had  re- 
course to  by  veterinary  surgeons,  not  so  much,  however,  to  en- 
able them  to  judge  accurately  of  disease,  and  to  prescribe  the 
proper  treatment,  as  to  aid  them  in  ascertaining  the  value  of  the 
animal  from  the  habitual  condition  of  its  respiration.*  In  this 
respect  they  are  greatly  assisted  by  the  nudity  of  the  subject. 
It  is  very  different  with  our  patients ;  to  whom  the  operation  of 
uncovering  the  chest  is  attended  with  so  many  inconveniences, 
that  it  is  no  wonder  that  this  method  of  exploration  has  been 
more  recommended  than  practiced.  Some  physicians  content 
themselves  with  causing  their  patients  to  take  a  few  deep  inspi- 
rations, without  uncovering ;  but  it  is  obvious  that  this  plan  is 
altogether  useless.  Indeed,  as  far  as  concerns  diagnosis,  the 
inspection  of  the  naked  chest  is  almost  equally  defective.  The 
respiration  is  considered  natural  when  the  anterior  and  lateral 
parts  of  the  chest  dilate  equally,  distinctly,  yet  moderately, 
during  inspiration,  and  .when  the  number  of  inspirations  in  a 
state  of  repose  is  from  twelve  to  fifteen  in  the  minute.f     If  the  abdo- 

*  I  learn  from  an  eminent  Veterinary  Surgeon  in  London,  that  it  is  the  prac- 
tice with  this  class  of  practitioners,  in  examining  the  soundness  of  a  horse,  to 
attend  to  the  sound  of  the  respiration  also,  by  the  application  of  the  ear  to  the 
vicinity  of  the  trachea. —  Transl. 

t  The  mean  number  of  inspirations  here  given  by  Laennec,  as  representing  a 
state  of  health,  is  evidently  too  low.  There  are  very  few  adults  who  do  not 
respire  more  than  twelve  or  fifteen  times  in  a  minute;  and  children,  of  course, 
respire  much  more  frequently  than  this.  The  mean  average  of  respirations  is 
more  than  sixteen  or  eighteen  in  the  minute, — and  most  persons  in  health 
breathe  from  eighteen  to  twenty-four  times  a  minute.  It  is  not  uncommon  to 
find  individuals  whose  lungs  are  sound,  and  who  exhibit  no  sign  of  disease,  yet 
breathing  twenty-six  and  twenty-eight  times  a  minute.  My  observations  on 
this  point  have  led  me  to  agree  with  Magendie,  that  in  a  healthy  adult,  the 
mean  number  of  respirations  in  a  minute  is  twenty,  rarely  less  than  sixteen, 
and  very  often  it  amounts  to  twenty-four  or  twenty-six.  In  infancy  the  mean 
number  is  greater ;  and  we  should  consequently  be  led  by  theory,  to  suppose 
that  as  old  age  approaches,  the  number  of  respirations  would  decrease;  but  this 
is  not  the  fact.  My  researches  enable  me  to  affirm,  that  after  sixty  years  of  age, 
the  mean  number  of  respirations  is  at  leasfTas  high  as  in  middle  life.  It  would 
appear  by  the  calculations  of  M.  M.  Hourmann,  and  De  Chambre,  that  it  is 
even  a  little  higher.  These  two  observers  have  stated  21,79  as  the  mean  num- 
ber of  respirations  in  two  hundred  and  fifty-five  women  at  the  Saipetriere  Hos- 
pital, who  were  in  good  health,  and  were  from  sixty  to  ninety-six  years  of  age. 
They  have  proved,  besides,  that  the  frequency  of  respiration  increases  with  de- 
crepitude. Aged  persons  therefore  suffer  no  abatement  either  of  breathing  or 
circulation.  The  researches  of  M.  M.  Leuret  and  Mitivie,  confirmed  by  those 
of  llourniann  and  De  Chambre,  establish  the  fact  that  in  old  age,  this  latter 
function  approaches  in  activity  the  state  which  characterized  it  in  infancy. 
The  mean  number  of  arterial  pulsations  is,  in  fact,  according  to  these  remarks, 
under  seventy  in  youth,  and  above  eighty  in  old  age.  The  frequency  of  respi- 
ration, however,  does  not  always  increase  with  that  of  circulation.  However 
rapid  tin-  latter  may  be,  the  respirations  hardly  ever  rise  -above  thirty  a  minute 
in  sound  lungs.  But  if  these  organs  be  diseased,  or  should  any  other  cause  ex- 
ist— as  an  affection  of  the  head  or  of  the  nervous  system,  for  instance,  to  ob- 


16  EXPLORATION    OF    THE    CHEST. 

men  dilates  with  comparatively  much  greater  force  than  the  chest, 
the  respiration  is  named  abdominal  ;  if  the  contrary  obtains,   it 
is  called  pectoral.     This  last  variety  is  especially  observed  in  cer- 
tain painful  affections  of  the  abdomen  :  but  the  diagnosis  of  these, 
especially  of  peritonitis,  is  so  easy  as  to  render  this  additional 
means  almost  superfluous.     The  abdominal  respiration  and  the 
defective  or  diminished  dilatation  of  the  chest,  are  very  generally 
considered   as   constantly  accompanying   extravasations  into    the 
pleura,  and  every  kind  of  pulmonary  obstruction.     This  opinion 
is,   however,  by  no  means   correct.     We  shall  afterwards  show 
that  the  extreme  dilatation   both  of  the  abdominal    and  thoracic 
parietes  in  inspiration,  occasionally  coincides  with  the  most  per- 
fect respiration,  as  far  as   regards  the  action  of  the  lungs  and  ex- 
pansion of  the  air-cells,  and  merely  indicates  an  increased  need  of 
respiration,  of  a  purely  vital  character:    while,  on  the  other  hand, 
a  diminished  expansion  of  the  same  parts    indicates  a  condition 
merely  the  reverse,\nd  which  is  found  to  vary  according  to  age, 
the  state  of  wakefulness  or   sleep,  of  motion   or  repose,   and  of 
calmness  or  agitation  of  mind.     Besides,  I  have  never  been  able 
to  ascertain  a  constant  and   very  obvious  inequality  of  action  in 
the  two  sides  of  the  chest,  except  in  cases  of  empyema  with  very 
large  effusion  or  of  deformity,  while   I  have  repeatedly  assured 
myself  that   the  dilatation  was    equable  in    phthisical    subjects, 
whose   lungs    were  very  unequally  charged  with  tubercles,  and 
likewise  in  cases  of  peripneumony  and  pleurisy  confined  to  one 
side  *     It  is  hardly  necessary  to  state  that  anasarcha,  fatness,  and 
very  large   mammae,   will  greatly  obscure   the   motions  of    the 
chest. 

The  pulsation  of  the  heart  is  visible  in  some  persons  between 
the  cartilages  of  the  fifth  and  seventh  ribs.  This  is  particularly 
the  case  in  children  and  thin  subjects,  with  small  bones  and 
narrow  chests,  but  is  no  indication  whatever  of  disease. 

From  these  considerations  it  must  be  concluded,  that  the  in- 
spection of   the  motions  of  the  chest  during   respiration,  is  of 

• 

struct  the  free  passage  of  blood  through  the  lungs,  respiration  rises  at  once  to 
thirty-six  or  forty,  and  sometimes  to  forty-five ;  but  seldom  beyond  this  :  al- 
though there  are  cases  in  which  it  may  rise  to  seventy.  I  have  known  persons 
affected  with  pneumonia,  to  breathe  with  this  remarkable  rapidity,  and  yet  to 
recover  thei%health.  If,  however,  a  patient  laboring  under  an  affection  of  the 
lungs,  has  more  than  fifty  respirations  a  minute,  he  must  be  considered  as  in  the 
greatest  danger. — Andral. 

*  Andral  states  (Clin.  Med.  t.  iii.  97.)  that  there  will  be  observed  a  greater  or 
less  degree  of  immobility  of  the  thoracic  parietes  over  the  site  of  a  lar<re  accu- 
mulation of  tubercles;  and  he  regards  it  as  indicating,  moreover,  the  presence 
of  a  chronic  inflammation  developed  in  the  lung  around  the  tubercles  or  tuber- 
culous cavities.  He  has  observed  it  chiefly  between  the  clavicle  and  nipple  •  it 
is  almost  constantly  conjoined  with  a  dull  sound  on  percussion.  Dr  JVIeriadec 
Laennec  has  never  observed  this  partial  immobility  of  the  walls  of  the  chest 
and  argues  against  its  probability.     I  have  certainly  observed  it.—  Transl 


ABDOMINAL    PRESSURE.  17 

little  utility.  Taken  by  itself  it  merely  shows  that  the  respira- 
tion is  impeded,  a  circumstance  equally  pointed  out  by  the  fre- 
quency of  the  inspirations  ;  while  in  conjunction  with  percus- 
sion and  mediate  auscultation  it  becomes  altogether  superfluous  • 
as  I  do  not  know  a  single  case  wherein  it  can  add  any  thino-  to 
the  certainty  of  the  results  obtained  by  them. 

In  lean  subjects  we  can  sometimes  distinctly  perceive  the  effect 
of  the  expansion  and  contraction  of  the  lungs,  in  the  alternating 
prominence  and  depression  of  the  intercostal  spaces  of  the  carti- 
lages of  the  upper  false  ribs ;  but  I  have  never  had  occasion  to 
make  any  useful  application  of  this  phenomenon  to  diagnosis.* 

Sect.  III.  Succussion  of  the  chest. 

By  succussion  1  mean  the  mode  of  exploration  used  by  Hip- 
pocrates or  some  of  his  early  disciples,  as  a  means  of  discovering 
the  presence  of  fluid  in  the  cavity  of  the  thorax.  This  method 
being  only  useful  in  two  particular  cases,  I  shall  defer  noticing 
it  until  I  come  to  treat  of  Pneumo-thorax  complicated  with  li- 
quid effusion. 

Sect.  IV.  Abdominal  pressure. 

This  method,  introduced  by  Bichat,f  consists  in  pressing  for- 
cibly upon  the  hypochondres  from  below  upwards,  and  watching 
the  degree  of  suffocation  and  distress  produced  by  it.  I  think 
this  proposal  can  only  be  regarded  as  an  unlucky  notion  incau- 
tiously dropped  by  a  man  of  fine  genius.     Bichat  had  himself 

*  I  think  that  the  author  has.  in  this  section,  somewhat  underrated  the  value 
Of  the  inspection  of  the  motions  of  the  chest,  as  a  means  of  diagnosis.  To  those 
who  do  Dot  employ  percussion  or  the  stethoscope,  this  method  of  exploration  is 
especially  valuable,  and  hails  to  important  practical  results,  when  the  pulse  and 
tongue  give  us  no  information,  or  mislead  as.  In  phthisis  which  has  been 
very  slow  in  its  progress,  and  when  tubercles  exist  in  both  lungs,  as  usually 
happens,  we  rind  both  sides  of  the  chest  contracted,  particularly  in  the  subcla- 
vian regions.  In  asthma,  on  the  contrary,  both  sides  are  usually  considerably 
dilated,  more  particularly  about  the  middle  of  the  chest,  and  rendered  much  more 
convex  both  before  and  behind.  In  old  asthmatics  this  configuration  of  the 
chest  is  sufficiently  conspicuous,  even  when  the  body  is  covered.  Its  presence 
is  always  a  proof  of  a  permanent  dilatation  of  the  pulmonary  cells,  and,  gener- 
ally, of  an  incurable  disease.  It  is  only  by  inspection  that  we  can  ascertain  cer- 
tain conditions  tif  the  mere  surf&ce,  which  are,  however,  often  of  importance  to 
diagnosis.  Ofthie  kind  are  oedema  of  a  portion  of  the  chest,  the  relative  width 
of  the  intercostal  spaces,  their  degree  of  prominence,  &c.  For  ampler  details 
on  this  subject  I  beg  leave  to  refer  the  reader  to  Double — Semiiologie  Generate, 
torn.  ii. ;  Landre-Heauvais — Simdotique,  p.  36;  Collin — Exploration  de  la  poi- 
i rim  .  p.  5,  and  also  to  the  second  and  third  volumes  of  Andral's  Clinique  Medi- 
tali  :  and  to  the  article  Chest,  Exploration  of,  in  the  Cyclopaedia  of  Pract.  Med. 
-  Transl. 

t  Memoire  sur  la  pression  abdominaJe,  par  M  Roux,  (Euv  Chirug.  de  De- 
fault, torn  ill     Paris,  1813. 

3 


18  EXPLORATION    OF    THE    CHEST. 

scarcely  made  trial  of  this  plan,  when  he  was  cut  off  in  the  prime 
of  life,  and  would,  no  doubt,  have  abandoned  it  after  a  little  ex- 
perience. The  relative  degrees  of  oppression  produced  by  it  in 
empyema,  peripneumony,  and  the  different  kinds  of  asthma, 
could  never  be  admitted  as  signs  deserving  confidence,  more  es- 
pecially as  a  high  degree  of  suffocation  is  produced  by  it  in  per- 
sons of  a  delicate  and  nervous  habit,  though  in  other  respects 
perfectly  healthy.  But  even  if  this  method  were  capable  of  sup- 
plying us  with  more  positive  indications,  it  ought  hardly  to  be 
had  recourse  to,  since  we  are  not  permitted  to  put  our  patients 
to  the  torture,  whatever  be  our  zeal  in  interrogating  nature.* 


CHAP.  II. 


OF    PERCUSSION. 


The  chest  of  a  healthy  person  when  slightly  struck,  ought  to 
yield  over  its  whole  extent,  more  particularly  in  its  anterior  and 
lateral  parts,  a  clear  and  distinct  sound,  owing  to  the  presence 

*  In  addition  to  the  Mcmoire  of  M.  lloux  above  referred  to,  the  reader  may 
consult  Corvisart's  work  on  Diseases  of  tiie  Heart.  ("2d  Edit.  p.  375,)  and  the 
Article  Pression  Mdominale,  by  Merat,  in  the  ^ J -"> t  J 1  Vol.  of  Diet.  des.  Sec.  Med. 

It  has  been  endeavored  to  ascertain  the  capacity  of  the  chest,  or  rather  of  the 
lungs,  on  another  principle,  namely,  by  ascertaining  the  quantity  of  air  the 
lungs  were  capable  of  containing.  This  method  was  proposed  by  the  late  Mr. 
Abernethy.  It  is  obvious  that  it  docs  not  had  to  the  same  results  as  mensura- 
tion of  the  external  surface  of  the  chest  ;  this  latter  giving  the  capacity  of  the 
containing,  the  former  the  capacity  of  the  contained  parts.  Mr.  Abernethy 's 
method  consists  in  making  the  patient  take  as  deep  an  inspiration  as  possible, 
and  then  expire  through  a  bent  tube  communicating  with  an  inverted  jar  con- 
taining water.  The  quantity  of  water  displaced  by  the  air  is  a  measure  of  the 
capacity  of  the  lungs  to  contain  air.  A  person  in  good  health  with  sound  lungs 
is  able  to  displace  six  or  eight  pints;  and  if  the  amount  be  greatly  less  than  this, 
as  for  example,  only  one-third  or  one-quarter,  it  may  be  inferred  that  the  lungs 
are  either  .obstructed  by  disease  of  their  own  sttbstauce,  or  compressed  from 
without.  "Muscular  debility  or  spasm,"  s.ivs  Air.  Abernethy,  "may  occasion- 
ally make  the  result  of  this  experiment  doubtful,  yet  in  general  I  believe  it  will 
afford  useful  information."  (Essays,  Part  II.  p.  157.)  In  this  judgment  I  agree 
with  Mr.  Abernethy. 

A  more  simple  lest  of  the  capacity  of  the  lungs,  founded  on  the  same  princi- 
ple, has  been  proposed.  (Edin.  Med.  Jour.  vol.  xxxviii.  p.  45:5^  It  consists  in 
measuring  the  comparative  length  of  time  occupied  in  making  a  complete  expi- 
ration after  a  complete  inspiration.  With  the  view  of  proving  that  the  expira- 
tion is  continuous,  tin-  patient  is  desired  to  count  from  one  upwards,  as  far  as  he 
can,  slowly  and  audibly  ;  and  the  number  of  seconds  during  which  he  is  able  to 
count,  without  drawing  breath,  is  noted  by  a  watch  .  the  number  of  seconds  is 
considered  a  proportional  sign  of  the  quantity  of  air  expired,  and  consequently 
of  the  capacity  of  the  lungs.  Dr.  Lyons,  who  proposes  this  method,  says,  that 
the  most  healthy  individual  will  not  continue  counting  beyond  thirty-five  sec- 
onds; but  in  this  he  is  certainly  mistaken,  as  any  of  my  long-winded  readers 


PERCUSSION.  19 

of  the  air,  which  constantly  fills  the  lungs,  and  consequently  a 
great  portion  of  the  cavity  of  the  thorax.  This  fact  was  no 
doubt  known  to  the  ancients  ;  and  in  our  own  times  there  are 
few  persons  who  have  not  seen  the  common  people  striking 
their  chests,  and  congratulating  themselves  on  the  good  hollow 
sound  thus  produced.  From  the  knowledge  of  this  fact,  to  the 
conclusion  that  the  same  sound  cannot  exist  in  cases  where  the 
lung  is  obstructed,  or  the  cavity  of  the  pleura  filled  with  fluid, 
seems  but  a  step ;  and  yet  this  reflection  appears  never  to  have 
occurred  to  any  one,  until  made  by  Avenbrugger,  about  the  mid- 
dle of  last  century.  After  seven  years  silent  investigation,  and, 
as  he  himself  tells  us,  amid  laborious  and  disgusting  researches 
(inter  labores  et  tadia,)  he  gave  his  discovery  to  the  world,  in  a 
small  pamphlet.  The  only  reward  he  seems  to  have  obtained  for 
his  fine  discovery,  was  a  slight  notice  of  it  by  Van  Swieten  and 
Stoll :  this  however  failed  to  attract  the  attention  of  his  contem- 
poraries, and  he  died,  without  ever  perhaps  dreaming  of  the  ce- 
lebrity which  his  discovery  was  destined  to  obtain.  Corvisart  is 
entitled  to  the  honor  of  withdrawing  this  method  from  the  ob- 
livion into  which  it  had  fallen,  after  a  period  of  thirty  years,  and 
of  making  all  Europe,  and  even  the  native  country  of  its  author, 
acquainted  with  its  merits.* 

This  method  has  the  advantage  of  not  requiring  the  use  of 
any  instrument ;  yet,  although  very  simple,  it  requires  long 
habit,  and  a  degree  of  dexterity  which  many  persons  are  inca- 
paple   of  acquiring.      The  slightest   variation  in  the  inclination 

may  prove  by  personal  experiment.  In  confirmed  phthisis,  Dr.  L.  says,  the  pe- 
riod of  expiration  never  exceeds  eight,  and  is  frequently  less  than  six  seconds ; 
while  in  pleurisy  and  pneumonia  it  may  range  from  four  to  nine.  This  test  is 
of  much  easier  application  than  Mr.  Abernethy's,  but  it  is  much  less  accurate : 
it  is  liable  to  vitiation  from  many  causes,  but  still,  like  Mr.  Abernethy's,  it  may 
be  occasionally  useful. —  Trait*/. 

*  Avenbrugger  was  born  in  Graets  in  Styria,  in  172-2.'  lie  graduated  at.  Vien- 
na, and  afterwards  became  physician  in  ordinary  of  the  Spanish  nation,  in  the 
imperial  hospital  of  that  city.  In  Erash  and  Puchelt's  LiteTOtur  dar  Mcdecin  he 
is  recorded  as  the  author  of  two  other  medical  works,  relating  to  madness,  one 
in  Latin,  published  in  1776,  and  the  oilier  in  German  in  1783.  In  the  same  re- 
cord Avenbrugger  is  staled  lo  have  died  mi  late  as  the  year  1809,  in  the  87th 
year  of  his  age.  The  work  on  Percussion  was  first  published  in  1761,  under 
the  title  of"  Inventum  varum,  ex  Percussiom  thoracis  humani,  ut  sin>io,abstrusos 
interni  pectoris  morbos  detegendi."  It  wasfirsl  translated  into  French  so  early  as 
the  year  1770,  by  Roziere,  but  appears  to  have  drawn  tittle  attention  at  the 
time.  Corvisart's  translation  was  published  in  1808.  The  only  English  trans- 
lation of  this  work  was  published  in  1.824,  with  a  selection  of  Corvisart's  Com- 
mentaries, and  additional  .Notes  by  the  translator  of  the  present  Treatise.  See 
"Original  Cases,  &c.  by  John  Forbes,  M.  D.  London,  1824."  It  is  stated  in 
the  notice  of  Lancisi,  in  the  Biographie  Medicale  (t.  5.  p.  502,)  that  this  physi- 
cian was  in  the  habit  of  employing  percussion  on  the  sternum  as  a  means  of  di- 
agnosis ;  but  upon  recently  referring  to  the  two  works  of  this  celebrated  author 
which  treat  of  diseases  of' the  (best.  (/><  Subitaneis  Morttbus  and  Be  Motu  Cor- 
dis ct  Jineurismalibus,)  I  cannot  find  any  indication  of  the  alleged  fact.—  Trans 


20  EXPLORATION    OF    THE    CHEST. 

under  which  the  fingers  strike  the  chest  may  give  rise  to  the 
belief  of  a  difference  of  sound  which  in  reality  does  not  exist. 
A  person  who  has  acquired  by  experience  a  certain  degree  of 
perfection  in  practice,  can  elicit  much,  little,  or  no  sound  at 
all,  from  a  chest  perfectly  sonorous ;  the  same  results  arc  fre- 
quently obtained  involuntarily  by  physicians  not  sufficiently  ex- 
perienced ;  some  of  whom,  moreover,  cannot  elicit  sufficient 
sound  without  employing  a  degree  of  force  which  is  painful  to 
the  patient. 

Mode  of  Percussion.  The  patient  ought,  if  practicable,  to 
be  either  seated  or  standing ;  if  in  bed,  the  mattress,  still  more 
the  pillows,  and  also  thick  curtains  always  render  the  sound  less. 
The  chest  ought  to  be  covered  with  a  thin  dress,  or  the  physi- 
cian should  have  a  glove  on.  This  precaution,  originally  re- 
commended by  Avenbrugger,  is  particularly  necessary,  inas- 
much as  the  contact  of  the  naked  hand  and  skin  occasions  a  sort 
of  clatter  which  renders  the  pectoral  sound  less  perfect  and  dis- 
tinct.* It  is  better  that  the  chest  should  be  covered  and  the 
hand  naked,  since  the  glove  necessarily  diminishes  the  sensibility 
of  the  touch,  and  because  the  sensation  of  elasticity  perceived 
by  the  operator,  frequently  confirms  his  judgment  in  cases  where 
the  difference  of  sound  is  only  doubtful.  In  every  case  the  percep- 
tion of  the  sense  of  fullness  or  emptiness  conveyed  by  percussion 
is  much  stronger  to  the  operator  than  the  mere  by-stander.  Per- 
cussion ought  to  be  made  with  the  four  fingers  united  in  one 
fine,  the  thumb  being  placed,  in  opposition  to  them,  at  the  junc- 
tion of  the  second  and  third  phalanges  of  the  index,  and  used 
merely  in  maintaining  the  fingers  in  close  and  strong  apposition. 
We  must  strike  with  the  ends  and  not  the  face  or  pulpy  portion 
of  the  fingers,  not  obliquely  but  perpendicularly,  and  gently 
and  quickly,  that  is,  raising  the  hand  immediately  from  the  skin. 

When  we  percuss  comparatively  the  two  sides  of  the  chest, 
we  must  be  careful  to  strike  successively  on  parts  that  are 
similar,  with  a  like  force  and  under  an  equal  angle  :  for  in- 
stance, we  must  not  strike  one  side  in  a  direction  parallel 
with  the  ribs,  and  across   them  on  the  other.      The    omission 

*This  injunction  of  having  the  chest  covered,  so  strongly  insisted  on  bv  the 
or.gmal  proposer  ..I  the  practice  and  In  our  author,  seems  to  me  of  inferior  con' 
sequence,  as  far  as itheaccuracy  of  diagnosisis  concerned,  [n  my  own  practice  1 
have  otter,  followed  the  mterdicted  method,  and  without  an,  inconvenience  as 

ferasl  am  aware.    A  much  greater  aul ity,  Corvisart,  did*  the  sam "and  he 

gives  it  as  Ins  opinion  that  percussion  max  be  equally  well    nerforrn    I 

way  as  the  other.     (See  his  Translation  of  Aw,,i!n,4,         ■>  '"  """ 

says  that  it  may  be  well  lor  beginners  to  attend  to  thegprecPautio„  ,-,  <  '  I   ,'  )'\ 

by  Avenbrugger.     1  would  furtheradd,  that  if  the  operation ca b equX  vS 

performed  over  a  garment,  (as  no  doubt   ilea...)  there  are    Fen,  obx  i  ' 

for  g,v,ng  this  mode  the  preference.     Our  autLr  omits  to Ze ^heTddTonS 

and  very  necessary  precaution,  given  bvAvp.nbriu.wor  , -  r  i       ■         , """"'" 

other  covering  tight  ove,  .1,,  pia?e  -T?aw7  §§    '  ""  *e  sl"rl  or 


PERCUSSION.  21 

of  these  precautions  frequently  leads  to  errors  of  consequence. 
If  we  keep  the  fingers  united  in  a  bundle  or  mass,  and  not  in  a 
line,  or  apply  them  under  an  oblique  angle,  so  that  their  face 
and  not  their  ends  come  in  contact  with  the  chest,  or  if  we  use 
too  much  force,  or  permit  the  fingers  to  rest  after  the  blow  is 
struck,  we  elicit  less  sound.  We  ought,  in  general,  to  apply 
percussion  to  the  bones,  and  not  to  the  intercostal  spaces,  and  to 
strike  the  anterior  a  ad  lateral  parts  of  the  chest,  in  a  direction 
parallel  to  the  ribs.  If,  however,  the  intercostal  spaces  are  not 
very  sensible,  as  frequently  happens  in  fat  or  phlegmatic  persons, 
it  is  better  to  strike,  across  the  ribs.  On  the  back  we  cannot  do 
otherwise  on  account  of  the  thickness  of  the  muscles ;  and  here 
we  ought  to  prefer  the  angles  of  the  ribs  as  being  least  covered, 
and  therefore  affording  the  best  sound.  In  any  point  where  the 
muscles  covering  the  ribs  are  thick,  flabby,  or  relaxed,  we  should 
endeavor  to  procure  their  tension.*  With  this  view,  when  we 
apply  percussion  over  the  pectorals,  we  cause  the  patient  to 
keep  the  trunk  erect,  the  shoulders  thrown  back,  and  the  head 
elevated  ;  and  in  applying  it  over  the  muscles  at  the  side  of  the 
spine  or  which  cover  the  scapula,  we  direct  the  arms  to  be  cross- 
ed, the  head  to  be  stooped,  and  the  back  to  be  rounded.  In  per- 
cussing the  axilla  and  side,  we  cause  the  arm  to  be  raised  and 
the  hand  to  be  placed  above  the  head.  If  the  muscles  are 
very  much  relaxed,  or  if  there  is  oedema  or  a  flabby  fatness,  it 
is  often  useful  to  stretch  and  compress  the  integuments  with  two 
fingers  of  the  left  hand,  and  to  strike  between.  In  the  case  of 
children  and  lean  persons,  it  is  found  sufficient  to  percuss  with 
the  extremity  of  one  finger.  In  subjects  whose  chest  is  naturally 
very  sonorous,  or  where  we  merely  wish  to  verify  results  already 
known  and  easily  obtained,  we  may  operate  more  expeditiously 
by  using  the  flat  of  the  hand,  taking  care  not  to  apply  the  palm. 
This  method,  however,  is  less  to  be  depended  on,  inasmuch 
as  the  percussion  extends  over  too  large  a  space,  and  is  somewhat 
different  under  each  finger.  In  these  cases  I  occasionally  em- 
ploy, and  with  more  success,  the  stethoscope,  in  percussing  ra- 
pidly the  parts  on  the  back,  especially  where  the  muscles  are 
flabby,  and  find  that  I  can  elicit  in  this  manner  a  greater  sound 
with  less  force  of  percussion. 

When  we  obtain  from  percussion  only  a  slight  difference  of 
sound  on  the  two  sides,  leaving  the  result  doubtful,  it  is  advisa- 
ble to  repeat  the  operation;  in  changing  our  position  to  the 
other  side  of  the  patient :  in  this  manner  we  frequently  obtain  a 
result  entirely  different,  the  side   most  sonorous  in  the  former 

"  This  is  loss  necessary  in  mediate  percussion  ;    indeed  ii  is  often  proper,  in 

tliis   method,  to  keep   tin    muscles   relaxed. — Piorry,  I)u  Procede  Opcnitoire 
Paris,  1830.— Tun,  si 


22  EXPLORATION  OF  THE  CHEST. 

trial  yielding  now  a  sound  inferior  to  the  other.  This  precau- 
tion is  never  to  be  omitted  in  doubtful  cases ;  for,  I  repeat  it, 
percussion  yields  exact  results  in  the  hands  of  those  only  who 
bring  to  its  exercise  experience,  dexterity,  and  much  atten- 
tion.* 

Character  of  the  sound  derived  from  Percussion.  This  is 
different  in  the  different  parts  of  the  chest;  on  which  account  I 
shall  divide  its  surface  into  fifteen  regions,  twelve  of  which  are 
double. 

1.  Subclavian  region.  This  includes  merely  the  portion  of 
the  chest  covered  by  the  clavicle.  When  struck  about  the  middle 
or  sternal  extremity,  this  bone  yields  a  very  clear  sound ;  its  hu- 
meral extremity  on  the  contrary  yields  a  rather  dull  sound.  The 
knowledge  of  the  natural  and  morbid  sound  of  the  chest  in  this 
region  is  very  important,  inasmuch  as  from  it  are  usually  derived' 
the  first  signs  of  the  developement  of  tubercles  in  the  lungs.f 
When  the  clavicle  is  more  distant  from,  or  closer  to,  the  chest 
than  usual,  in  consequence  of  the  more  arched  or  straighter  form 
of  this  bone,  the  sound  is  less  distinct :  this  is  especially  the  case 
in  the  latter  condition  of  the  clavicle. 

2.  Anterior-superior  region.  This  is  bounded  by  the  clavicle 
above  and  the  fourth  rib  (inclusive)  below.  The  sound  is  here 
naturally  very  clear,  but  somewhat  less  so,  however,  than  oveY 
the  sternal  end  of  the  clavicle. 

3.  Mammary  region.  This  begins  below  the  fourth  rib  and 
terminates  with  the  eighth.  It  can  rarely  be  percussed  in  fe- 
males ;  and  in  the  male  it  seldom  yields  so  good  a  sound  as  the 
anterior-superior  region,  on  account  of  the  thickness  of  the  infe- 
rior edge  of  the  pectoralis  major. 

4.  Submammary  region.  This  extends  from  the  eighth  rib  to 
the  cartilaginous  border  of  the  false  ribs.  On  the  right  side,  it 
almost  yields  a  dull  sound  on  account  of  the  size  of  the  liver ; 
while  on  the  left  side,  it  frequently  yields  a  clearer  sound  than 
natural,  and  which  may  be  called  almost  tympanitic,  owing  to 
the  presence  of  the  stomach  distended  with  gas.     In  very  rare 

*As  the  intensity  of  sound  depends  partly  on  the  quantity  of  air,  it  follows  that 
the results  of  percussion  will  be  modified  by  the  particular  time,  in  the  art  of  respi- 
ration, at  which  it  is  performed  ;  and  as  we  are  always  desirous  of  eliciting  as  loud 
a  sound  as  possible,  it  is  generally  preferable  to  percuss  during  or  immediately  after 
inspiration,  when  the  lungs  are  full ;  and  not  during  or  after  expiration  when 
they  are  comparatively  empty.  In  obscure  casts,  it  is  frequently  necessary  or 
at  least  proper,  to  make  the  patient  take  a  deep  inspiration,  and  then  retain  his 
breath  for  a  few  seconds,  while  we  operate.-^ Transl. 

t  It  is  now  well  known  that  tubercles  occupy  the  upper  lobes  of  the  lun<rs   oar 
lier  and  in  greater  quantity,  than  the  other  lobes.     See  the  chapter  on  Phthisis 
in  this  work.     See  also  Louis's  Rcc/icrches  sur  la  Plrihisic,  Chap   II    n   224  — 
Transl.  '  ' 


f  PERCUSSION.  23 

instances  the  unusual  size  of  the  spleen  may  occasion  the  dull 
sound.* 

5.  Sternal  regions — superior,  middle,  and  inferior.  Over  the 
whole  extent  of  the  sternum  the  sound  is  as  clear  as  on  the  sternal 
end  of  the  clavicle.  In  certain  cases,  however,  particularly  in 
very  fat  persons,  the  lower  portion  of  the  sternum  yields  a  duller 
sound  on  account  of  the  great  quantity  of  fat  about  the  heart.f 

6.  Axillary  region.  This  extends  from  the  upper  part  of 
the  axilla  to  the  fourth  rib  inclusive ;  it  yields  naturally  a  clear 
sound. 

7.  Lateral  region.  This  is  bounded  by  the  fourth- rib  above 
and  terminates  with  the  eighth.  The  sound  in  this  region  is 
always  good  on  the  left  side  ;  on  the  right,  it  is  frequently  much 
less,  owing  to  the  liver  rising  higher  than  usual,  and  thereby 
compressing  the  lung  upwards,  and  rendering  it  more  dense  and 
less  charged  with  air.  The  liver  itself  never  extends  above  the 
level  of  the  sixth  or  fifth  rib,  at  least  when  sound. 

8.  Inferior  lateral  region.  This  is  bounded  above  by  the 
eighth  rib  and  terminates  with  the  border  of  the  false  ribs.  For 
the  reason  just  mentioned,  this  .region  on  the  right  side  yields  a 
completely  dull  sound,  and  is  almost  always  much  less  sonorous 
than  the  left.  This  last,  on  the  contrary,  for  reasons  also  already 
•stated,  frequently  yields  a  clearer  .sound  than  natural,  and  this 
even  when  the  inferior  portion  of  the  lung  is  obstructed,  or  there 
exists  an  effusion  of  fluid  in  the  pleura. 

9.  Acromion  region.*  This  is  comprehended  between  the  cla- 
vicle, the  upper  edge  of  the  trapezius  muscle,  the  head  of  the 
humerus,  and  the  lower  part  of  the  neck.  Here  there  is  no 
sound  whatever,  the  soft  parts  in  this  place  yielding  passively  to 
the  percussion. 

10.  Upper  scapular  region.  This  corresponds  to  the  supra- 
spinal fossa  of  the  scapula,  and  hardly  yields  any  sound  on  ac 
count  of  the  muscle  that  fills  it.  The  spine  of  the  scapula, 
which  bounds  this  region  below,  sometimes  yields  a  slight  sound, 
but  never  considerable,  and  this  only  when  the  arms  are  very 
forcibly  crossed. 

11.  Lower  scapular  region.     This  corresponds  to  that  portion 

*  Andral  is  of  opinion  that  flic  dullness  of  thia  region  on  the  left,  owing  to  the 
presence  of  the  spleen,  is  of  more  frequent  occurrence  than  is  commonly  imagined. 
Ton..  II.  p.  338.— Transl. 

\  .Avenbrugger  considers  this  diminution  of  sound,  under  a  part  of  the  ster- 
num as  general.  His  words  ar< — "Sternum  lotum  percussum  resonat  ita  clare 
ac  thoracis  tatera  accepto  i  I  Jo  loco,  cui  cor  pro  parte  subjacet;  ibi  enim  paulo  ob- 
scurioi  Minus  percipitur."  The  opinion  of  Con  isart  coincides  with  that  of  our 
author.  I  have  myself  frequently  found  the  sound  dull  in  this  point,  when  there 
no  reason  to  suspect  disease  ofthe  heart. —  Transl 


24  EXPLORATION    OF    THE    CHEST. 

of  the  scapula  below  its  spine,  and  yields  no  sound,  on  account 
of  its  muscles. 

12.  Inter-scapular  region.  This  includes  the  space  between 
the  inner  margin  of  the  scapula  and  the  spine,  when  the  arms 
are  crossed  on  the  breast.  It  is  not  easy  to  elicit  any  sound 
from  it,  on  account  of  its  muscles.  Sometimes,  however,  it 
yields  a  middling  but  sufficiently  distinct  sound,  especially  in 
thin  persons,  and"  when  the  arms  are  strongly  crossed  and  the 
head  bent,  so  that  the  rhomboid  and  trapezius  muscles  are  made 
quite  tense.  The  spine  in  this  region  gives  a  good  sound,  as 
does  also  that  portion  of  the  chest  included  between  the  inner 
and  upper  angle  of  the  scapula  and  the  first  dorsal  vertebra. 

13.  Inferior  dorsal  region.  This  begins  at  the  level  of  the 
lower  angle  of  the  scapula  and  terminates  at  the  twelfth  dorsal 
vertebra.  To  elicit  from  this  region  all  the  sound  it  is  capable 
of  yielding,  we  ought,  especially  in  fat  subjects,  to  endeavor 
to  find  the  angle  of  the  ribs,  and  to  percuss  on  that  point  in  a 
transverse  direction.  In  the  upper  part  of  the  region,  the  sound 
is  pretty  good ;  a  little  lower  it  is  often  slight  or  none,  and  on 
the  right  side  it  is  almost  always  obscure,  on  account  of  the 
presence  of  the  liver.  On  the  left  side  it  frequently  yields  the 
factitious  sound  so  often  mentioned  as  owing  to  the  presence  of 
the  stomach.* 

*  Independently  of  the  relative  sonorousness  of  different  parts  in  the  same 
chest,  general  differences  occur  in  different  individuals;  which  it  is  not  always 
easy  to  account  for;  some  chests  being  very  sonorous,  and  others  comparatively 
dull.  This  might  be  expected,  a  priori,  when  the  complexity  of  the  structure 
of  the  contained  and  containing  parts  is  considered.  The  greater  or  less  degree 
of  robustness,  fatness,  <&c.  has  certainly  an  obvious  effect;  lean  persons  having 
always,  ceteris  paribus,  more  sonorous  chests  than  those  who  are  fat.  This  is 
one  reason  why  percussion  frequently  fails  to  detect  the  presence  of  tubercles  in 
the  lungs,  the  increase  of  sonorousness  from  the  extenuation  ofparietes  compen 
sating  for  the  augmented  dullness  of  the  viscus  within.  In  children  generally, 
the  chest  is  very  sonorous.  This  may  partly  arise  from  the  small  degree  of  de- 
velopemcnt  of  their  muscles,  and  the  absence  of  fat;  but  it  is  probably,  also,  in 
part  owing  to  the  peculiar  relations  of  the  lungs  to  the  air,  in  this  age. 

M.  Piorry  has  recently  given,  in  his  work  on  Mediate  Percussion,  a  different 
division  of  the  surface  of  the  chest,  into  regions.  It  is  in  some  respects  erven 
more  artificial  than  that  of  our  author,  and  1  am  not  aware  thai  it  has  any  supe- 
rior practical  advantages.  It  is  vety  desirable,  for  the  sake  of  brevitj  and  clear- 
ness in  description,  as  well  as  for  the  precision  in  diagnosis,  that  some  fixed 
division  should  be  adopted. 

In  the  article  Abdomen,  Exploration  of,  in  the  first  vol.  of  the  Cyclopaedia  of 
Pratt.  Med.  I  have  given  a  sketch  of  a  regional  subdivision  of  the  trunk  of  the 
body, simpler  than  that  of  Laennec  or  Piorry,  and  based  on  somewhat  firmei 
grounds.  In  this  [went  upon  the  fundamental  principle  of  defining  every  re- 
gion accurately,  in  every  individual  case,  by  drawing  all  the  lines  perfectly 
straight,  and  between  points  that  arc  at  once  fisted  in  their  nature  and  obvious 
to  the  senses.  By  these  mem-  there  ■  an  never  be  any  doubt  as  to  the  intended 
place  or  extent  of  particular   regions,  whatever  objections  may  be  raised  againsl 

the  propriety  of  the  divisions.     The  abd en   a  ml  chest  arc   comprehended  in 

the  same  plan,  but  1  shall  only   notice  in  this  place  the  thoracic   regions.     Thi 
vertical  lines  having  relation  to  the  chest  are  eight  in  number,  and  run  as  fol 


PERCUSSION.  25 

Percussion  of  the  chest  has  great  advantages  over  the  methods 
already  noticed.  It  enables  us  to  detect  the  existence  of  an  ob- 
struction of  the  lungs  or  an  effusion  into  the  pleura  of  a  moderate 
extent ;  but  it  cannot  discriminate  these  from  each  other.*  Many 
causes,  moreover,  conspire  to  circumscribe  the  number  of  cases 
in  which  it  is  of  use.  We  have  just  seen  that  in  many  places  of 
the  chest  it  gives  no  satisfactory  result,  and  it  was  formerly 
stated  that  its  chief  indication  (that  of  fullness)  is  not  obtained 
in  pulmonary  diseases  until  the  organic  change  is  already  far 
advanced.  Its  indications  are  very  equivocal  when  the  disease 
occupies  the  centre  or  roots  of  the  lungs,  or  when  both  lungs 
are  simultaneously  affected ;  they  are  deceptive  when  the  chest 
is  deformed  even  in  a  slight  degree ;  and  they  are  extremely  un- 
certain or  cease  entirely  when  the  integuments  are  oedematous  or 

lows  : — 1.  along  the  middle  of  the  sternum  from  its  upper  to  its  lower  extremi- 
ty ;  2.  from  the  acromial  extremity  of  the  clavicle  to  the  external  tubercle  of 
the  pubes  (right  and  left)  ;  3.  from  the  posterior  boundary  of  the  axilla,  or  infe- 
rior edge  of  the  latissimus  dorsi,  to  that  point  of  the  crest  of  the  ileum  on  which 
it  tails  vertically  (right  and  left) ;  4.  along  the  spinous  processes  of  the  cervical 
and  dorsal  vertebra;;  5.  along  the  posterior  or  spinal  border  of  the  scapulae,  from 
the  clavicular  transverre  line  to  the  mammary  transverse  line.  The  horizontal 
or  transverse  lines  are  four  in  number,  and  are  as  follows  : — 1.  around  the  lower 
part  of  the  neck,  sloping  downwards  to  the  upper  end  of  the  sternum  anteriorly, 
and  to  the  last  cervical  vertebra  posteriorly ;  2.  around  the  upper  part  of  the 
chest  in  the  line  of  the  clavicles;  3.  around  the  middle  of  the  chest,  crossing  the 
nipples  anteriorly,  and  touching  the  inferior  borders  of  the  scapula;  behind;  4. 
around  llie  lower  part  of  the  chest  on  the  scyphoid  cartilage. 

l$y  these  imaginary  lines  the  trunk  is  divided  into  three  horizontal  and  eight 
vertical  bands,  and  their  intersections  form,  in  all,  sixteen  compartments  or  re- 
gions, of  which  two  are  superior,  four  anterior,  four  lateral,  (two  on  each  side,) 
and  six  posterior.  They  are  named  as  follows  : — superior  regions — humeral 
(right and  left) ',  anterior  regions — subclavian  (right  and  left),  mammary  (right 
and  left;)  Intend  regions — axillary  (right  and  left),  subaxillary  or  lateral  (right 
and  left;)  posterior  regions — scapular  (right  and  left),  intra-scapular  (right  and 
left),  subscapular  or  superior  dorsal  (right  and  left.) 

There  are  few  more  useful  exercises  for  the  anatomical  student  than  endeav- 
oring to  imprint  on  his  mind  some  plan  of  this  kind,  and  to  teach  himself  by  ob- 
servation, and  by  multiplied  experiment  on  the  dead  subject,  the  precise  rela- 
tions of  the  regions  to  the  viscera  that  lie  beneath  them.  He  ought  always  to 
consider  his  knowledge  as  imperfect,  until  he  is  able  to  state,  with  considerable 
accuracy,  the  organs,  or  parts  of  organs,  that  will  be  wounded  by  a  stiletto  thrust 
in  at  any  point.  It  is  only  after  possessing  such  a  degree  of  knowledge,  that  he 
can  enter,  with  full  advantage,  upon  the  study  of  the  various  methods  used  in 
exploring  diseases  of  the  chest  or  abdomen,  and  that  he  can  expect  to  derive 
from  them  the  great  practical  benefits  which  they  are  calculated  to  supply. — 
Trn  us/. 

*  A  congestion  of  the  tissue  of  the  lungs,  n  ery  seldom  of  itself  causes  a  sound  so 
lint  and  of  such  wide  extent  as  that  caused  by  a  plentiful  effusion  in  the  pleura?. 
Great  dullness  of  sound  on  one  whole  side  of  the  thorax,  affords,  then,  if  not 
an  absolute  certainty,  at  least  a  very  strong  presumption  in  favor  of  the  exist- 
ence of  a  pleuritic  effusion,  rather  than  of  pneumonia  or  tubercular  state  of  the 
lung.  1  have  known  several  eases  where  a  sound  quite  as  dull  as  that  attending 
an  effusion,  arose  from  the  existence  of  enormous  cancerous  masses  in  the  pleu- 
rae between  the  ribs  and  the  lung.  But  this  lesion,  however,  is  a  rare  occur- 
rence, and  can  seldom  be  mistaken  lor  a  pleuritic  effusion.  The  natural  sound 
of  the  chest  may  be  diminished  more  or  less  by  false  membranes  found  in  the 
pleura,  and  which  sometimes  grow  very  thick. — Jin  d  ml. 

4 


26  EXPLORATION    OF    THE    CHEST. 

loaded  with  fat,  and  yet  more,  when  they  have  become  flabby 
from  the  removal  of  this  excessive  degree  of  obesity. 

We  occasionally  also  meet  with  cases  where  the  chest,  even  of 
spare  subjects,  sounds  very  badly,  and  equally  so  over  its  whole 
surface,  although  the  respiration  is  found  to  be  good  on  the  appli- 
cation of  the  stethoscope.  I  am  unacquainted  with  all  the  causes 
of  this  phenomenon ;  but  the  most  common  has  appeared  to  me 
to  be  a  slight  and  equal  contraction  of  both  sides,  the  consequence 
of  pleuritic  attacks  which  had  produced  numerous  adhesions  be- 
tween the  lungs  and  costal  pleura.* 

However,  if  percussion  taken  singly  frequently  furnishes  us 
only  with  indications  which  are  circumscribed  and  often  doubt- 
ful, it  becomes  most  valuable  when  combined  with  mediate  aus- 
cultation ;  and  we  shall  find  hereafter  that  the  pathognomonic 
signs  of  several  important  diseases,  and  among  others  of  pneumo- 
thorax, emphysema  of  the  lungs,  and  the  accumulation  of  un- 
softened  tubercles  in  the  upper  lobes,  are  derived  from  the  con- 
temporaneous employment  of  these  two   methods.f 

*  There  is  an  objection  to  percussion  of  another  kind,  which  I  do  not  remem- 
ber to  have  seen  mentioned  by  any  one,  but  which  it  has  occurred  to  me  more 
than  once  to  witness, — namely,  the  alarm  produced  in  the  minds  of  the  patients 
upon  their  perceiving  a  great  difference  of  sound  in  the  two  sides.  In  this  res- 
pect, as  in  most  others,  mediate  auscultation  has  a  decided  advantage  ;  as,  how- 
ever ominous  may  be  the  results  obtained  by  it,  we  can  always  conceal  them 
from  the  patient. —  Transl. 

\  An  important  improvement  on  the  method  of  percussion  was  recommended 
some  time  since  by  M.  Piorry,  and  has  been  fully  explained  and  illustrated  in 
the  following  two  valuable  treatises  published  by  him:  Dela  Percussion  Mediate. 
Par.  1828.  8.  Du  procede  Operatoirc  a  suivrc  dans  V exploration  des  organes  par  la 
Percussion  Mediate  Par.  1830.  8.  This  improvement  consists  in  interposing  be- 
tween the  point  of  the  fingers  and  the  chest,  a  small  plate  of  ivory  on  which 
the  percussion  is  made  ;  and  from  which  circumstance  the  inventor  has,  in  im- 
itation of  Laennec,  given  the  name  of  Mediate  Percussion  to  his  method.  The 
ivory  plate  (which  has  received  the  name  of  Pleximeter  or  Plcssimcter,  from  the 
words  TT\>'ia<xo),  I  strike  or  7rA>j|is,  percussion,  and  jiirpov,  measure,)  is  of  a  circular 
or  ovoid  shape,  from  an  inch  and  a  half  to  two  inches  in  diameter,  and  about  ono 
sixth  of  an  inch  in  thickness.  It  has  either  a  raised  edge  or  rim,  or  projecting 
handles  on  its  upper  side,  to  permit  its  being  held  between  the  finger  and  thumb 
of  the  left  hand,  while  it  is  struck  with  the  right.  In  making  use  of  this  instru- 
ment, all  that  seems  essential  is  to  apply  it  accurately,  closely,  and  consequently 
parallel  to  the  surface.  As  in  simple  percussion,  the  blow  maybe  made  with  one 
or  more  fingers,  and  must  be  rapidly  executed,  with  the  points  but  not  the  na£Ls  of 
the  fingers  :  on  this  account  the  nails  must  be  kept  short.  The  pleximeter  may  be 
applied  immediately  on  the  skin  or  over  some  portion  of  the  clothes ;  and,  as  in 
the  case  ol  the  stethoscope,  it  is  necessary  on  some  parts  to  interpose  a  small 
pledget  of  lint  or  soft  linen,  to  insure  its  accurate  apposition. 

The  following  are  the  relative  advantages  and  disadvantages  of  the  two  meth- 
ods, as  stated  by  M.  Piorry.  1.  Direct  percussion  is  often  painful,  particularly 
in  unskillful  hands;  as  when  the  blows  are  too  forcible,  when  they  are  applied 
upon  the  soft  parts  between  the  ribs,  or  when  the  nails  are  prominent  :  even,  in 
some  cases,  the  degree  of  impulse  necessary  to  produce  sufficient  sound  excites 
either  a  sense  of  pain  on  the  skin,  or  a  painful  jarring  within  the  chest,  occa- 
sionally lasting  some  time.  The  use  of  the  pleximeter  enables  us  to  avoid  all 
these  inconveniences  ;  in  the  first  place,  because  it  defends  the  skin  from  the 
direct  impulse  of  the  fingers  ;  secondly,  because  a  less  degree  of  impulse  is  nc- 


27 
CHAP.    III. 

OF    IMMEDIATE    AUSCULTATION. 

Hippocrates  had  made  trial  of   immediate  auscultation,  as    is 
proved   by  the  following   passage   of  the  treatise  De,  Morbis ; 

ccssary  to  produce  the  requisite  6ound  ;  and,  thirdly,  because  the  shock  is  much 
less  felt  from  being  equally  diffused  over  a  considerable  space.  Even  in  the  case 
of  recent  vesications,  the  interposition  of  the  plate  will  frequently  enable  us  to 
employ  percussion  with  little  or  no  inconvenience  to  the  patient.  2.  As  the 
walls  of  the  thorax  consist  of  very  different  materials  in  different  places,  and  vary 
likewise  greatly  as  to  their  thickness,  &c.  direct  percussion  can  only  be  effective 
when  made  on  the  more  solid  points  of  the  thinner  parts  of  the  parietes  ;  namely, 
the  sternum,  clavicles,  ribs,  and  their  cartilages  :  when  made  on  the  intercostal 
spaces,  pectoral  muscles,  or  mamma-,  it  is  both  painful  and  ineffective  ;  and  when 
there  is  a  great  accumulation  of  fat  below  the  skin,  or  the  parts  are  anasarcus  or 
emphysematous,  the  sound  is  still  more  imperfect.  Mediate  percussion  will  en- 
able us  to  get  over  most  of  these  difficulties.  By  means  of  the  interposed  plate 
we  can  percuss  equally  on  the  bone  and  soft  parts  ;  and  the  precaution  so  requi- 
site in  direct  percussion,  to  percuss  on  similar  parts  on  both  sides,  becomes  unne- 
cessary, the  plate  constituting  a  sort  of  artificial  solid  wall  to  the  soft  parts.  In 
the  case  of  anasarca  or  emphysema,  by  compressing  the  distended  parts  with  the 
plate,  we  obtain  a  solid  point  whereon  to  employ  percussion,  and  thereby  obtain 
results  otherwise  unattainable.  3.  Mediate  percussion  is  much  easier,  and  re- 
quires much  fewer  precautions  than  the  ancient  method.  In  direct  percussion 
we  must  never  lose  sightof  the  rule  that  the  percussion  must  lie  made  precisely 
in  the  same  manner  on  the  two  opposite  sides  of  the  (best,  to  enable  us  to  de- 
duce safe  conclusions  from  resulting  sounds:  for  instance,  the  blows  must  be 
made  on  similar*structures,  with  the  same  degree  of  force,  under  the  same  an- 
gle, &c.  Witli  the  pleximeter  these  precautions  arc  much  less  necessary,  be- 
cause we  have  here  always  the  same  flat  smooth  surface  whereon  to  strike,  and 
an  artificial  wall  every  where  of  equal  density  and  elasticity.  Besides,  less  art  is 
necessary  in  arranging  the  fingers  in  the  bitter  case,  a  single  finger  being  in  gene- 
ral   sufficient  to  elicit  the  necessary  degree  of  sound. 

In  admitting  the  validity  of  these  advantages  of  mediate  over  direct  percussion, 
we  must  allow  that  the  superiority  of  either  in  practice  will  depend  greatly  on 
experience.  By  one  well  versed  in  direct  percussion,  an  instrument  will  not 
often  be  needed  in  the  exploration  of  the  chest,  as  his  experience  will  enable 
him  to  evade  most  of  the  inconveniences  attending  the  former.  The  necessity 
of  carrying  an  instrument,  however  portable,  will  he  fell  by  some  to  be  an  incon- 
venience ;  but  this  can  never  be  admitted  as  a  reason  for  rejecting  the  employ- 
ment of  a  method  which  possesses  decided  advantages. 

There  is  a  variety  of  mediate  percussion  in  common  use  still  more  simple  than 
that  of  Piorry's,  and  which  is  well  deserving  the  attention  of  the  student.  This 
consists  of  the  substitution  of  one  or  two  lingers  of  the  left  hand  for  the  plexim- 
eter,— the  back  of  the  fingers  being  uppermost.  This  proceeding  possesses  sev- 
eral of  the  advantages  of  M.  Piorry's  method  ;  and  it  has  even  some  few  over  it, 
exclusive  of  its  greater  simplicity.  In  cases  where  there  is  considerable  emaci- 
ation, M.  Piorry's  method  is  liable  to  mislead,  unless  the  intercostal  spaces  are 
carefully  filled  with  some  soft  material  ,  as,  without  this  precaution,  the  sound 
may  be  modified  by  the  hollow  existing  between  the  plate  and  the  skin.  Di- 
rect percussion  on  the  ribs,  or  the  employment  of  the  fingers  as  a  pleximeter,  is 
often,  in  such  cases,  preferable,  [f  we  are  careful  in  applying  the  fingers  so  as 
Jo  make  them  fit  accurately  into  the  natural  depressions,  and  thus  form  one  body. 
as  it  were,  with  the  thoracic  parietes. — we  are  often  enabled  to  use  verj  forcibh 
percussion  without  exciting  pain,  and  also  to  elicit  as  definite  sound-;  as  by  eithei 
of  the  other  methods     This  proceeding  is  free  from  another  inconvenience  which 


28  EXPLORATION    OF    THE     CHEST. 

"  You  shall  know  by  this  that  the  chest  contains  water  and  not 
pus,  if  in  applying  the  ear  during  a  certain  time  on  the  side,  you 

occasionally  attaches  to  M.  Piorry's  method,  especially  in  the  hands  of  beginners. 
In  the  latter  it  sometimes  happens  that  the  loudness  and  sharpness  of  the  pri- 
mary sound  arising  from  the  contact  of  the  two  surfaces,  are  so  considerable 
(particularly  if  the  nail  be  used,  which  it  ought  never  to  he)  as  to  drown,  as  it 
were,  the  secondary  sound  resulting  from  the  modifying  influence  of  the  subja- 
cent parts,  from  which  modification  it  is  that  we  form  our  judgment  respecting 
the  condition  of  those  parts".  When  the  fingers  constitute  the  pleximcter,  we 
have  little  or  none  of  this  immediate  clatter  when  the  blow  is  given. 

In  the  percussion  of  the  abdomen,  possessed  as  it  is  of  soft  and  yielding  walla 
only,  the  pleximcter  is  absolutely  necessary  to  the  production  of  the  requisite 
degree  of  sound  ;  and  it  is  vet  further  necessary,  in  many  cases,  in  order  to  bring 
the  superficial  walls,  by  pressure,  in  contact  with  the  subjacent  parts.  Mediate 
percussion  alone  may  therefore  be  said  to  be  applicable  to  the  investigation  of 
abdominal  diseases.  Ft  is  at  least  equally  applicable  with  direct  percussion  to 
the  chest ;  and  as  it  has  decided  advantages  in  some  cases,  and  no  other  disad- 
vantage in  any  case  than  the  necessity  of  having  an  additional  instrument,  it 
ought  to  take  precedence  of  the  original  method  of  Avenbruggcr  in  the  investi- 
gation of  pectoral  diseases  only. 

An  observation  above  stated  by  Laennec  in  the  text,  (p.  20,)  that  the  indica- 
tions from  percussion  conveyed  to  the  operator  are  much  stronger  than  to  the  by- 
standers, ought  never  to  be  overlooked  in  practice  :  the  peculiar  sensations  in- 
dicative of  the  absence  or  presence  of  air  in  the  subsequent  parts,  are  often  dis- 
tinctively appreciable  as  communicated  through  the  percussing  fingers,  when 
the  difference  of  sound  is  imperceptible. 

Different  things  have  been  used  as  pleximeters,  and,  among  others,  the  horn  cap 
which  is  now  commonly  affixed  to  the  auricular  extremity  of  the  stethoscope. 
M.  Piorry  objects  to  this  on  account  of  the  liability  of  horn  to  warp,  and  also 
on  account  of  the  perforation  in  its  centre.  Dr.  Williams,  however,  seems  to 
consider  this  last  as  no  objection,  but  recommends  the  inner  surface  of  the  cap 
to  be  lined  with  soft  leather,  to  prevent  the  clacking  noise  produced  by  the 
impulsion  of  the  fingers. — (Rational,  Exposition,  p.  22.) — My  own  experience  is 
against  the  use  of  the  perforated  pleximcter;  exclusively  of  an  objection  I  have 
to  the  cap  of  the  stethoscope  being  so  made  as  to  be  easily  removed.  In  M. 
Piorry's  .Stethoscope,  the  ivory  plexiraeter  is  attached  to  its  pectoral  extremity, 
and  indeed  forms  a  necessary  part  of  it.  This  arrangement  is  convenient,  and 
is  perfectly  satisfactory  as  far  as  percussion  is  concerned;  but  I  have  already 
objected  to  the  whole  instrument  regarded  as  a  stethoscope.  See  plate  at  the 
end. —  Transl. 

In  this  clear  and  accurate  notice  of  the  different  sounds  observed  to  arise 
from  different  points  of  the  chest  when  percussed,  it  is  remarkable  that  Laennec 
should  have  forgotten  to  mention  the  diminution  of  sound  caused,  in  most  cases, 
by  the  presence  of  the  heart  in  the  left  submammary  region.  Here  a  dull  sound  is 
heard,  which  in  a  healthy  condition  of  the  heart,  occupies  a  space  of  1J  or  2 
inches  square,  as  has  been  stated  by  M.  M.  Piorry  and  Bouillaud,  and  verified 
by  my  own  observation.  But  it  does  not  follow  that  the  real  size  of  tlie  heart 
corresponds  exactly  to  these  dimensions :  the  measurement  above  stated,  only 
shows  the  space  where  this  organ  is  not  covered  by  the  lung.  But  in  relation 
to  this  point  there  is  a  great  difference  in  individuals— for  it  sometimes  happens 
that  an  increase  in  the  size  of  the  heart  will  not  extend  the  space  of  the  dull 
sound  in  the  precordial  region.  Sometimes  it  happens  that  instead  of  the  nat- 
ural dullness  of  the  thorax  below  the  left  breast,  there  is  a  very  distinct  sound- 
yet  the  heart,  far  from  being  diminished  in  volume,  as  would  be  conjectured 
is  much  enlarged.  This  may  be  remarked  daily  in  eases  of  pulmonary  emphy- 
sema, where  the  dilatation  or  rupture  of  the  vesicles  exists  in  that  portion  of 
the  lung  which  lies  immediately  beneath  the  cartilages  of  the  left  ribs  An 
enlargement  of  the  heart  or  a  dilatation  of  its  cavities  often  accompanies  this 
morbid  state  of  the  lung,  yet  percussion  of  the  precordial  region  will  rive  no 
indication  of  the  fact.  Apart  from  this  pathological  condition,  a  perfectly  heal 
thy  lung  may,  in  various  individuals,  cover  various  portions  of  the   heat   and 


IMMEDIATE    AUSCULTATION.  2i> 

perceive  a  noise  like  that  of  boiling  vinegar."*  I  need  hardly 
slate  that  the  assertion,  as  far  as  the  diagnosis  is  concerned,  is 
erroneous.  The  sound  heard  by  Hippocrates  was  probably  that 
of  simple  respiration,  or  this  intermixed  with  a  crepitous  rhonchus. 
It  is  very  singular  that  this  passage  seems  never  to  have  engaged 
the  attention  of  physicians,  and  there  is  no  evidence  that  his  experi- 
ment has  ever  been  repeated,  until  the  present  time.  It  is  true  that 
I  had  myself  read  this  passage  of  Hippocrates  many  years  before 
I  entertained  the  idea  of  mediate  auscultation ;  but  at  the  time  I 
considered  it,  as  it  indeed  is,  one  of  the  mistakes  of  the  great  man, 
and  had  altogether  forgotten  it.  If  Hippocrates  had  prosecuted 
this  line  of  inquiry  further,  there  is  no  doubt  that  he  would  havo 
discovered  many  valuable  truths,  and  might  perhaps  have  arrived 
at  mediate  auscultation  itself.  But  he  seems  to  have  proceeded 
no  further  than  to  announce  the  incorrect  observation  above 
quoted,  and  which  his  successors  appear  to  have  totally  disre- 
garded. This  seems  at  first  sight  wonderful ;  and  yet  nothing 
is  of  more  common  occurrence :  it  is  not  given  to  any  man  to 
comprehend  all  the  relations  and  all  the  consequences  of  the  most 
simple  fact;  and  we  know  that  nature's  secrets  are  more  fre- 
quently betrayed  by  fortuitous  circumstances  than  obtained  by 
the  force  of  our  scientific  efforts. 

Since  the  publication  of  my  researches,  some  physicians  have 
attempted  to  repeat  them  by  immediate  auscultation  ;  and  there 
is  one  or  two  of  these  who  seem*  to  give  this  method  the  pre- 
ference. Their  chief  reasons  are — that  it  saves  the  trouble  of 
carrying  an  instrument ;  that  it  enables  us  to  perceive  more 
sounds  at  once,  and  therefore  more  intelligibly ;  and  that  it  is 
more  easy  to  apply  the  ear  than  to  keep  the  stethoscope  in  exact 
contact  with  the  side. 

These  reasons  are  more  specious  than  well  founded.  It  is 
true  that  the  ear  applied  to  the  chest  enables  us  to  hear  more 
sounds  than  we  do  by  the  stethoscope,  particularly  if  the  use  of 
this  instrument  is  not  familiar  to  us.  But  this  arises  chiefly  from 
this  circumstance,  that  all  the  parts  of  the  observer's  head  which 
bear  upon  the  chest,  namely,  the  cheek-bone,  the  temples  and  the 
angle  of  the  jaw,  become,  severally,  conductors  of  sound,  and  may 
thus  convey  the  Sound  of  respiration  to  the  ear,  although  none 

alter  the  results  of  percussion,  while  the  size  of  the  heart  remains  the  same. 
The  existence,  therefore,  of  a  dull  sound  in  the  region  of  the  heart  over  a 
wider  extent  than  common,  indicates  that  the  heart  or  its  envelope  is  diseased  ; 
but  the  absence  of  the  dull  sound  does  not  enable  us  to  say  for  a  certainty  that 
the  heart  is  not  enlarged. — Andral. 

*  Tofircj)  av  yvoirjs,  on  ov  nvov,  dXXd  iiliwp  wri.  Kal  ijv  ttoWuv  ^pdvov  -npoat^iav  to  ovs 
aicovafo  rrpos  ra  irltvpa  u$ci  iao>0ts  olov  4'6p»S-     De  Morbig,  U.  §  f>!t.  Vanderlindcn. 

In  the  translation  in  the  text  I  have  followed  the  interpretation  (the  only 
reasonable  one)  adopted  by  Vanderlinden,  Comaro,  and  Mcrcurialis,  as  if  it 
were  {««  (fervct)  in  place  of  «f«  (old)— Author. 


30  EXPLORATION    OF    THE    CHEST. 

exists  immediately  beneath  it.  This  circumstance  may  lead  to 
serious  mistakes  in  cases  where  the  pulmonary  obstruction  is 
partial  and  of  small  extent.  To  a  person  who  has  never  tried 
either  of  the  methods,  it  is  no  doubt  an  easier  matter  to  apply 
the  ear  to  the  chest  than  to  make  use  of  the  stethoscope  :  although 
the  habit  of  using  this  instrument  may  be  acquired  in  a  very  few 
days.  But  there  exist  innumerable  reasons  which  will  always 
render  mediate  auscultation  a  much  surer  guide  and  of  much 
more  extensive  employment.  I  will  here  notice  some  of  the  prin- 
cipal of  these : — 

1.  We  cannot  apply  the  ear  to  many  points  of  the  chest  where 
important  signs  most  frequently  are  found,  such  as  the  axilla,  tho 
region  of  the  acromion,  the  angle  formed  by  the  clavicle  and  tho 
head  of  the  humerus,  (in  lean  persons,)  the  lower  end  of  the 
sternum  when  much  depressed,  and,  frequently  also,  the  inter- 
scapular region.  In  the  case  of  females,  exclusively  of  reasons  of 
decorum,  it  is  impracticable  over  the  whole  space  occupied  by  the 
mammae. 

2.  Immediate  auscultation  is  more  fatiguing  to  the  patients 
than  is  the  application  of  the  stethoscope,  inasmuch  as  this  last 
bears  only  on  one  small  point  and  needs  hardly  any  pressure, 
while  the  due  application  of  the  naked  ear  requires  a  considerable 
pressure  on  the  chest. 

3.  Owing  to  this  circumstance,  it  gives  rise  to  extraneous 
sounds  from  the  contraction  of*  the  muscles,  in  keeping  up  the 
pressure,  as  we  shall  see  afterwards  :  and  the  friction  of  the  ear 
and  head  against  the  patient's  clothes,  produces  much  more 
sound  than  when  the  stethoscope  is  used.  I  have  more  than 
once  had  occasion  to  see  physicians,  or  pupils,  mistake  these 
extraneous  sounds  for  those  of  respiration.  This  mistake  is  more 
easy  from  the  circumstance  of  the  factitious  sounds  being,  like 
those  of  respiration,  subject  to  regular  intermission  from  the 
natural  motions  of  the  chest. 

4.  The  uneasy  posture  which  one  is  frequently  forced  into, 
determines  the  blood  to  the  head  and  renders  the  hearino-  dull' 
This  circumstance,  and  the  repugnance  which  every  one  must 
feel  to  apply  the  ear  to  a  patient  that  is  dirty  or  whose  chest  is 
bathed  in  perspiration,  must  always  prevent  the*  habitual  or  fre- 
quent use  of  this  method ;  and  this  single  circumstance  takes 
from  it  three-fourths  of  its  value;  for,  independently  of  the 
want  of  experience  which  must  be  the  necessary  result  we 
thereby  deprive  ourselves  of  the  very  best  and  most  practical 
advantage  of  auscultation,  that,  namely,  of  recognizino  disease* 
at  their  commencement:  since  at  this  period  they  are  almost 
always  latent,  and  the  discovery  of  them  can  therefore  only  be 


IMMEDIATE    AUSCULTATION.  31 

made  by  those  who  are  accustomed  to  explore  the  respiration  in 
all  cases  whatsoever. 

5.  Moreover,  some  of  the  most  important  of  the  stethoscopic 
signs  have  for  one  of  their  causes  the  stethoscope  itself.  Thus, 
perfect  pectoriloquy,  which  consists  in  the  transmission  of  the 
voice  through  the  tube  of  the  instrument,  is  changed,  in  the 
trial  of  immediate  auscultation,  into  a  simple  resonance,  stronger 
no  doubt  in  the  natural  condition  of  the  parts,  but  such  as  to  be 
with  difficulty  discriminated  from  agophony  and  bronchophony. 
For  these  and  other  reasons,  I  do  not  hesitate  to  affirm,  that  the 
physicians  who  shall  confine  themselves  to  immediate  auscultation, 
will  never  acquire  great  certainty  in  diagnosis,  and  will  every  now 
and  then  fall  into  serious  mistakes.* 

*  I  entirely  agree  with  the  sentiment  expressed  by  M.  Meriadec  Laennec,  in  his 
note  on  this  passage,  that  the  wise  and  peremptory  reflections  made  by  our  au- 
1  lior  respecting  the  vast  superiority  of  mediate  over  immediate  auscultation,  are  un- 
answerable.. The  only  instances  in  which  I  have  found  immediate  auscultation 
preferable,  have  been  in  certain  diseases  of  infants,  who  are  sometimes  too  rest- 
less or  too  timid  to  allow  the  proper  application  of  the  instrument;  while  inthe 
infinite  majority  of  cases,  it  has  been  proved  to  be  decidedly  inferior  lor  every 
purpose  of  practical  value.  To  use  the  words  of  Dr.  Williams,  and  at  the  same 
time  to  strengthen  my  testimony  by  the  weight  of  bis  high  authority,  "  I  would 
express  my  conviction  that  although,  with  a  view  to  expedition  and  convenience, 
immediate  auscultation  may  be  occasionally  substituted,  no  one  who  has  once 
thoroughly  trained  his  ears  to  the  use  of  the  stethoscope,  will  ever  so  lightly  es- 
teem its  aid  as  again  to  abandon  it." — (Cyc.  of  Prac.  Med.,  vol.  iv.  Art.  Stetho- 
scope.)— Transl. 

Immediate  auscultation  does  not  merit  the  reproach  here  bestowed  on  it. 
The  ear  may  be  applied  readily  to  almost  every  part  of  the  surface  of  the 
chest:  where  this  cannot  be  done,  the  stethoscope  maybe  used;  such  cases 
however  are  rare.  I  have  not  found  that  the  application  of  the  car  is  more 
troublesome  to  the  patient  than  the  stethoscope.  On  the  contrary,  the  manner 
in  which  some  physicians  apply  the  instrument  is  painful  to  the  patient,  and 
gives  rise  to  much  complaint.  In  some  positions  of  the  patient  in  bed,  it  is  im- 
possible for  the  most  expert  hand  to  hold  the  stethoscope  sufficiently  firm  to 
keep  it  in  the  right  place.  For  example,  when  a  patient  lies  upon  a  bed  which 
is  approachable  only  on  one  side,  and  the  stethoscope  is  to  be  applied  to  the 
further  side  of  the  chest,  the  instrument  is  imperfectly  fixed,  and  the  physician 
cannot,  as  he  applies  his  ear  upon  it,  maintain  a  proper  equilibrium ;  in  such 
cases,  immediate  auscultation  can  be  practised  without  difficulty.  I  have  never 
found  that  the  action  of  the  muscles  of  the  observer,  as  Laennec  asserts,  has 
the  effect  of  producing  sounds  that  may  be  confounded  with  those  arising  from 
the  chest  of  the  patient.  If  this  ever  takes  place,  the  observer  must  certainly 
make  other  exertions  than  those  necessary  for  the  simple  application  of  the  ear. 
With  regard  to  the  other  sounds  mentioned  by  the  author,  as  caused  by  the 
friction  of  the  ear  against  the  patient's  clothing,  they  are  assuredly  not  louder 
than  the  sounds  of  the  same  kind  made  by  the  movements  of  the  stethoscope. 
When  the  car  is  held  immovable,  and  the  clothing  drawn  tight,  these  sounds 
never  occur.  The  mistakes  on  this  point  which  Laennec  mentions,]  have 
seen  committed  by  physicians  with  the  stethoscope,  just  as  he  has  known  them 
committed  by  others  with  the  naked  ear.  The  inexperienced  auscultator  may 
fall  into  the  same  enor  by  both  methods  of  auscultation.  And  I  will  observe 
here,  that  it  requires  more  lime  and  practice  to  auscultate  successfully  with  the 
stethoscope  than  with  the  naked  ear.  It  is  seldom  the  case,  I  think,  that  the 
constrained  posture  of  the  observer,  while  practicing  mediate  auscultation,  is 
such  as  to  cause  a  flow  of  blood  to  the  head  sufficient  to  disturb  his  sense  of 
hearing.     On   the  contrary,  the   application  of  the  ear  simply,  demands  a  less 


3.2  i;\l'LORATION    OF 


chap.  iv. 


OF  MEDIATE  AUSCULTATION. 


The  signs  afforded  by  mediate  auscultation  in  the  diseases  of 
the  lungs  and  pleura,  are  derived  from  the  changes  presented  by 
the  sound  of  respiration,  by  that  of  the  voice  and  coughing, 
within  the  chest,  and  also  by  the  rhonchus,  as  well  as  certain 
other  sounds  which  occasionally  are  heard  in  the  same  situation. 
Of  these  signs  we  shall  now  proceed  to  give  some  account.  The 
notice  of  those  which  refer  to  the  diseases  of  the  heart,  will  be 
deferred  until  we  come  to  treat  of  the  affections  of  this  organ. 

The  general  precautions  which  the  practice  of  auscultation 
requires  are  the  following: — 1.  The  stethoscope  must  be  applied 
very  exactly  and  perpendicularly  to  the  surface  on  which  it  rests, 
so  as  to  leave  no  interval  between  the  skin  and  any  part  of  the 
extremity  applied. — 2.  We  must  be  careful  not  to  produce  pain 
by  too  strong  pressure ;  this  precaution  is  most  necessary  when 
the  instrument  is  used  without  the  stopper,  and  when  the  person 
is  lean. — 3.  Although  it  is  not  necessary  that  the  chest  should  be 

constrained  position  in  the  physician  than  the  use  of  the  stethoscope.  As  to 
the  oiFensive  condition  of  the  patient  from  want  of  cleanliness,  &c.  a  remedy 
is  easily  found  in  placing  a  handkerchief  or  a  napkin  over  the  surface  to  bo 
examined.  Laennec  thinks  that  less  will  be  learnt  from  the  immediate  auscul- 
tation, as,  on  account  of  its  inconveniences,  it  is  likely  to  be  less  practised ; 
but  we  have  shown  that  no  such  inconveniences  exist:  and  as  the  ear  is  more 
at  our  command  than  the  stethoscope,  my  opinion,  contrary  to  that  of  Laennec 
is  that  the  ear  is  more  likely  to  be  used,  and  consequently  more  experience  will 
be  gamed  from  it,  than  by  the  use  of  any  acoustic  instrument  whatever. 

Neither  can  I  agree  with  him  that  the  stethoscope  is  better  than  the  ear  for 
distinguishing  the  sounds  of  the  part  under  consideration  from  those  proceeding 
from  the  adjacent  parts.  I  have  never  found  any  difference  in  this  respeel  be- 
tween the  two  methods  of  auscultation.  Pectoriloquy  becomes  sometimes 
indeed,  a  little  more  distinct  and  perfect  under  the  stethoscope,  although  the 
naked  ear  can  distinguish  it  very  well. 

What  I  have  already  said  of  the  comparative  advantages  of  the  two  methods 
of  auscultation,  applies  equally  to  the  respiratory  organs  and  the  heart —Ami 
I  will  add,  that  1  have  repeatedly  been  able  to  distinguish  some  of  the  bruits 
de  soufflet  more  clearly  with  the  ear  than  with  the  instrument 

My  own  experience,  therefore, 'confirmed  by  that  of  many  others   enables  me 
to  affirm  that  immediate  auscultation,  when  it  can  be  employedfWm  ^ fumUh 
evidence  as  clear  and  exact,  as  that  obtained   by  means  of  the  stethoscope  a 
that  the  employment  of  the  instrument    is  necessary  in    only  a  small  ,„„  ,V,-.i 
of  eases.     It  ,s  indispensable,  for  instance,  in  sonfe  cases  „    ,,    ,    r        |    J',' 
the  walls  Of  the   chest,  ,n  winch    the  application  of  the  ear   is  imp,,,  , 

order  to  distinguish  more  clearlj  the  phenomena  of  pectoriloquy,  and,  observe 
the   sounds  of  the   arteries,  the   carotid   in   particular.     With        ,       x 
these  cases,   immediate  auscultation    has  all   the  advantages    ,    i,    "  £  ,  d 

should  be  preferred  as  .he  more  simple  method,  and  the  one  in  whicl    i  Jo 
rator  is  always  sure  ol  having  his  instrument  at  hund.-.^W  P 


THE    RESPIRATION.  33 

uncovered, — as  all  the  positive  stethoscopic  signs,  and  frequently 
also  the  negative  ones,  may  be  perceived  through  clothes  of  con- 
siderable thickness,  provided  they  are  applied  closely  to  the  body, 
— still  it  is  better  that  the  clothing  should  only  be  light ;  for  ex- 
ample, a  flannel  waistcoat  and  shirt.  Silks  and  also  woollen  stuffs 
are  often  inadmissible  on  account  of  the  noise  occasioned  by  their 
friction  against  the  instrument.  The  examiner  ought  to  be 
careful,  above  all  things,  not  to  place  himself  in  an  uncomfortable 
posture,  nor  yet  to  stoop  too  much,  nor  turn  his  head  backwards 
by  a  forced  extension  of  the  neck.  These  positions  determine 
the  blood  to  the  head  and  thus  obscure  the  sense  of  hearing : 
they  may  sometimes  be  properly  avoided  by  kneeling  on  one 
knee.  In  examining  the  fore  parts  of  the  chest  we  ought  to 
place  the  patient  on  his  back  in  a  recumbent  position,  or  in  a 
chair,  and  gently  reclining  backwards.  When  we  examine  the 
back,  we  cause  the  patient  to  lean  forwards  and  to  keep  his  arms 
forcibly  crossed  in  front ;  and  when  we  examine  the  side,  we 
cause  him  to  lean  gently  to  the  opposite  one  and  to  place  the  fore 
arm  on  the  head. 


Sect.  I.  Auscultation  of  the  respiration. 

In  exploring  the  respiration  we  use  the  instrument  without  its 
stopper.  In  commencing  our  examination  it  is  a  proper  precau- 
tion to  cause  the  patient  to  take  a  few  inspirations  of  moderate 
force  and  frequency,  followed  by  expirations  as  nearly  as  may  be 
of  the  same  length.  It  sometimes  happens  that  perfectly  sound 
lungs  give  hardly  any,  or,  at  most,  a  very  feeble  respiratory 
sound :  and  in  these  cases  it  is  commonly  found  that  the  sound 
is  weak  in  proportion  to  the  effort  made  by  the  patient  to  make 
it  audible.  At  other  times  our  patients  fancying  that  something 
uncommon  is  expected  from  them,  expand  their  chests  to  the 
very  utmost  extent ;  or  they  make  several  strong  inspirations, 
one  after  another,  without  any  intervening  expiration  ;  these 
unnatural  efforts  produce  hardly  any  respiratory  sound.  In 
such  cases,  and  indeed  in  all  others  where  the  sound  of  respira- 
tion is  found  to  be  weak,  we  desire  the  patient  to  cough.  The 
act.of  coughing,  particularly  intentional  coughing,  is  commonly 
preceded  or  followed  by  a  real  inspiration,  which  is  then  found  to 
be  as  sonorous  as  the  particular  condition  of  the  organ  admits  ; 
and  in  these  cases  we  are  frequently  surprised  to  perceive  the 
ready  penetration  of  the  air  into  lungs  which  we  should  have 
considered  as  impermeable,  if  we  had  relied  on  our  first  trials. 
We  sometimes  obtain  a  similar  end  in  making  the  patient  speak, 
♦  5 


34  EXPLORATION    OF 

and  still  more,  in  making  him  read  or  recite.*  I  state  tins  fad 
not  only  because  it  is  of  practical  importance,  but  because  it 
tends  to  the  conclusion  that  the  lungs  are  themselves  possessed 'of 
an  inherent  power  of  action,  the  scat  of  which  is  probably  in  the 
smaller  bronchial  ramifications. 

The  sound  of  respiration  is  different  in  the  lungs,  the  trachea, 
and  the  larger  bronchial  tubes,  respectively.  These  differences 
we  shall  now  describe. 

1.  Vesicular  respiration.^  On  applying  the  cylinder,  with  its 
funnel-shaped  cavity  open,  to  the  breast  of  a  healthy  person,  we 
hear,  during  inspiration  and  expiration,  a  slight  but  extremely 
distinct  murmur,  answering  to  the  entrance  of  the  air  into,  and 
its  expulsion  from,  the  air-cells  of  the  lungs.  This  murmur  may 
be  compared  to  that  produced  by  a  pair  of  bellows  whose  valve 
makes  no  noise,  or,  still  better,  to  that  emitted  by  a  person  in  a 
deep  and  placid  sleep,  who  makes  now  and  then  a  profound  in- 
spiration.! We  perceive  this  sound  almost  equally  distinct  in 
every  part  of  the  chest,  but  more  particularly,  in  those  points 
where  the  lungs,  in  their  dilatation,  approach  nearest  to  the  tho- 
racic parietes,  for  instance,  the  anterior-superior,  the  lateral,  and 
the  posterior-inferior  regions.  The  hollow  of  the  axilla,  and  the 
space  between  the  clavicle  and  superior  edge  of  the  trapezius 
muscle,  exhibit  the  phenomenon  in  its  greatest  intensity. 

To  judge  correctly  of  the  state  of  respiration  by  this  method, 
we  must  not  rely  on  the  results  of  the  first  moments  of  examina- 
tion. The  sort  of  buzzing  sensation  often  caused  by  the  first 
application  of  the  instrument,  the  fear,  restraint,  and  agitation  of 
the  patient,  which  mechanically  lessen  the  force  of  respiration, 
the  frequently  inconvenient  posture  of  the  observer,  and  the  great 
sensation  occasionally  produced  by  the  action  of  the  heart, — are 
all  causes  which  may  at  first  prevent  us  from  correctly  appreci- 
ating, or  even  from  hearing  at  all,  the  sound  of  inspiration  and 
expiration.  We  must,  therefore,  allow  some  seconds  to  pass  be- 
fore we  attempt  to  form  an  opinion.  I  need  hardly  observe,  that 
there  must  be  no  noise  whatever  in  the  vicinity  of  the  patient. 

I  have  already  mentioned  the  necessity  of  the  observer  avoid- 

*  No  doubt  all  these  artificial  modes  of  increasing  the  intensity  of  the  respi- 
ratory sound  are  effectual,  and  are  occasionally  necessary  ;  in  the" great  majqrity 
of  cases,  however,  a  little  patience  is  all  that  is  wanted  to  lead  to  the  most  sat- 
isfactory result ;  after  a  minute  or  two  of  quiet  exploration,  the  natural  charac- 
ter of  the  respiration  will  generally  be  perceived. —  Transl. 

t  I  have  ventured  to  substitute  the  term  vesicular  respiration,  introduced  by 
Andral,  for  that  of  pulmonary  employed  by  our  author,  as  being  at  once  more 
precise,  and  contrasting  better  with  the  other  varieties  to  be  noticed  below.  In 
this  I  am  supported  by  the  authority  of  Dr.  Meriadec  Laennec,  in  his  new  edi- 
tion of  the  Treatise. —  Transl. 

%  The  student  will  most  readily  catch  its  true  character,  by  applying  the  na- 
ked ear  to  the  chest  of  a  child. —  Transl. 


THE    RESPIRATION.  35 

ing  uneasy  postures.  Besides  the  inconveniences  stated,  this 
may  also  mislead  by  occasioning  the  auscultator  to  hear  the  sound 
of  the  contraction  of  his  own  muscles.  We  must  be  equally  on 
our  guard  that  the  patient  does  not  excite  this  sound  in  his  own 
muscles,  by  too  strong  a  contraction  of  them  in  crossing  the 
arms,,  leaning  forward  or  resting  on  the  elbow.  On  this  account, 
in  the  examination  of  weak  subjects,  it  is  always  better  to  have 
them  supported  by  assistants,  than  to  make  them  exhaust  their 
remaining  strength  in  keeping  themselves  in  the  erect  position. 
It  is  right  to  observe,  however,  that  all  these  precautions  are  only 
necessary  to  beginners.  After  one  or  two  months'  experience, 
the  ear  becomes  accustomed  to  the  sound  it  is  in  search  of,  and  is 
able  to  discriminate  it  from  all  the  others  with  which  ft  may  be 
combined,  even  when  weaker  than  they  are. 

The  intervention  of  clothing,  even  when  of  considerable  thick- 
ness, provided  it  be  of  a  compact  texture  and  fit  the  body  well, 
does  not  sensibly  diminish  the  sound  of  respiration  ;*  but  we 
must  be  careful  that  there  is  no  friction  between  this  and  the  in- 
strument, as  this  circumstance,  especially  if  the  clothes  be  of  silk, 
or  of  fine,  hard,  woollen  stuff,  may  mislead  us  by  exciting  a 
sensation  analogous  to  that  produced  by  respiration.  Fatness, 
even  when  excessive,  and  anasarca  of  the  chest,  seem  to  have  no 
effect  in  diminishing  the  peculiar  sound.  The  sound  is  more 
distinct  in  proportion  as  the  respiration  is  more  frequent.  #A  very 
deep  inspiration  made  very  slowly,  will  sometimes  be  scarcely 
audible,  while  an  imperfect  respiration — such,  for  instance,  as 
hardly  at  all  elevates  the  chest,  provided  it  be  made  quickly, — 
may  produce  a  very  loud  sound.  On  this  account,  when  ex- 
amining a  patient,  more  especially  if  we  have  had  but  slight 
practice  with  the  instrument,  we  should  desire  the  respiration 
to  be  performed  rather  quickly.  This  is,  however,  a  very  unne- 
cessary precaution  in  most  diseases  of  the  chest,  as  the  frequent 
presence  of  dispncea  necessarily  renders  the  respiration  quick. 
The  same  is  true  of  fever,  and  the  agitation  caused  by  nervous 
affections. 

Many  other  causes,  and  especially  the  age  of  the  individual, 
alter  the  intensity  of  the  sound.  In  children  respiration  is  very 
sonorous,  even  noisy,  and  can  be  heard  easily,  even  through  very 
thick  clothing.  In  them  the  close  and  forcible  application  of  the 
instrument,  to  prevent  the  friction  of  the  garments,  is  unneces- 
sary, as  any  noise  that  might  arise  from  this  cause  is  lost  in  the 

*  This  must  not  be  taken  too  literally,  except  in  the  case  of  children,  or 
when  the  respiration  is  morbidly  strong.  In  adults,  the  intensity  of  the  re- 
spiratory sound  is  certainly  considerably  lessened  by  thick  clothing,  even  where 
there  is  no  extraneous  sound  from  friction;  and  in  all  cases  it  is  better  to  have 
the  body  covered  only  with  one,  or,  at  most,  two  folds  of  linen  or  cotton  cloth, 
(i.  e   the  shirt.)  and  not  with  flannel. —  Transl 


36  EXPLORATION    OF 

intensity  of  the  other.  The  respiration  of  children  differs,  also, 
from  that  of  adults  in  other  respects  besides  its  intensity.  It  is 
impossible  to  describe  this  peculiarity,  but  it  will  easily  be  under- 
stood by  comparative  trials.  It  appears  as  if,  in  children,  we 
could  distinctly  hear  the  dilatation  of  all  the  air-cells  to  their 
full  extent ;  whilst,  in  adults,  these  seem  as  if,  from  their,  stiff- 
ness, they  could  only  bear  a  partial  dilatation.  This  difference 
of  sound  is  much  less  marked  in  expiration  than  inspiration. 
The  dilatation  of  the  chest  in  inspiration  is  also  greater  in  the 
child ;  and  both  these  peculiarities  are  more  remarkable  as  the 
child  is  younger ;  they  continue,  in  a  greater  or  less  degree,  to 
the  period  of  puberty  or  a  little  beyond  it. 

The  sound  produced  by  respiration  varies,  also,  very  much  in 
its  intensity  in  different  adults.  In  some  men  it  is  scarcely  per- 
ceptible unless  they  make  a  very  deep  inspiration,  and  even  then, 
although  sufficiently  distinct,  it  is  not  one  half  so  audible  as  in 
the  majority  of  persons.  These  individuals  have  generally  a 
rather  slow  respiration,  and  are  little  subject  to  dyspnoea,  or 
breathlessness,  from  any  cause.  Others,  however,  have  the  re- 
spiration very  distinct  even  during  a  common  inspiration,  without 
being,  on  this  account,  at  all  more  subject  to  shortness  of  breath 
than  the  former.  Some  few  individuals,  again,  preserve  through 
life  a  state  of  respiration  resembling  that  of  children,  and  which 
I  shall  therefore  denominate  puerile,  in  whatever  age  it  may  be 
perceptible.*  Such  persons  are  almost  all  women,  or  men  of  a 
nervous  temperament,  and  they  preserve,  in  some  other  respects, 
the  character  of  childhood.  Some  of  these  cannot  be  said  to 
have  any  actual  disease  of  the  lungs,  but  they  soon  get  out  of 
breath,  even  though  lean,  by  exercise,  and  are  very  liable  to 
catch  cold.     Others  of  this  class  are  affected  with  a  chronic  ca- 

*  The  alteration  in  structure  which  takes  place  in  the  lungs  in  the  progress 
from  infancy  to  old  age,  accounts  for  the  remarkable  difference  in  the  intensity 
of  vesicular  respiration  at  different  ages.  It  may  be  laid  down  as  a  general 
principle,  that  its  intensity  is  in  direct  proportion  to, the  density  of  the  pulmo- 
nary tissue.  As  the  individual  approaches  the  natural  termination  of  his  career 
the  parenchyma  of  the  lungs  become  rarefied ;  a  certain  number  of  pulmonary 
vesicles,  which  in  infancy  and  adult  age  are  completely  separated  by  partitions 
become,  later  in  life,  united,  by  the  gradual  failure  and  disappearance  of  these 
partitions:  from  this  time  the  air  gains  admission  into  larger  cavities  but  the 
surface  over  which  it  plays  is  evidently  diminished.  There  is  still'  a  great 
difference  among  aged  persons  with  reg;ird  to  the  degree  of  rarefaction  of  the 
pulmonary  tissue.  In  some  instances  the  lungs  maintain  a  density  nearly  equal 
to  that  in  the  adult:  these  old  people  are  not  decrepid — but  have  much  of  the 
adult  character,  both  in  general  constitution  and  pulmonary  structure.  In  other 
aged  persons,  we  find  the  pulmonary  tissue  m  a  state  of  rarefaction  never  seen 
in  adults  except  in  disease.  These  old  persons  unlike  the  others,  are  thin  and 
emaciated,  in  whom  nutrition  is  but  feebly  and  imperfectly  performed.  In  a 
word,  they  experience  at  an  early  age  a  decrepitude  which  the  others  feel  very 
late  in  life  or  never.  If  we  compare  the  respiratory  murmur  in  these  two 
classes  of  old  persons,  we  shall  find  it  very  strong  in  the  one,  and  very  weak  in 
the  other. — Andral. 


THE    RESPIRATION.  37 

larrli,  attended  by  dyspnoea,  a  condition  constituting  one  of  those 
cases  to  which  the  name  of  Asthma  is  usually  given.  With  these 
exceptions,  an  adult  cannot,  by  any  effort,  give  to  his  respiration 
the  sonorous  character  it  has  in  childhood ;  but  in  some  morbid 
states,  the  respiration  spontaneously  acquires  it,  without  being, 
at  the  lime,  performed  more  forcibly  than  usual.  This  is  parti- 
cularly the  case  when  one  whole  lung,  or  a  considerable  portion 
of  both  lungs,  is  rendered  impermeable  to  air  through  disease, 
especially  acute  disease.  In  the  sound  portion  of  the  lungs,  in 
these  cases,  the  respiration  is  perfectly  similar  to  that  of  children. 
The  same  thing  is  observable  throughout  the  whole  extent  of  the 
lungs  in  some  cases  of  fever,  and  in  certain  nervous  diseases :  [and 
also  in  cases  in  which  tubercles  are  disseminated  throughout  lungs 
otherwise  healthy ;  and  in  the  earlier  stages  of  diseases  of  the 
heart.]* 

At  first  we  are  tempted  to  believe  that  the  superior  intensity 
of  the  respiratory  murmur  in  children,  may  be  owing  to  the 
tenuity  of  the  muscles  covering  the  chest,  and  to  the  superior 
suppleness  of  the  texture  of  the  lungs.  But  the  first  cause  must 
have  scarcely  any  effect  in  this  way,  since  we  find  that,  even  in 
the  fattest  children,  and  in  those  most  thickly  clothed,  the  respi- 
ration is  much  more  distinct  than  in  the  leanest  adult  examined 
uncovered  ;  whilst  of  the  adults  who  possess  the  puerile  respira- 
tion, many  are  very  robust  and  full  of  flesh.  Neither  does  the 
quieter  respiration  of  the  adult  depend  on  any  induration  or  loss 
of  pliability  in  the  pulmonary  texture,  since  it  sometimes  acci- 
dentally returns  to  the  character  it  had  in  infancy.  I  am  rather 
disposed  to  believe  that  the  difference  of  result  depends  on  the 
fact  of  children  requiring  a  greater  proportion  of  air,  and  conse- 
quently a  fuller  inspiration,  than  adults ;  whether  this  necessity 
arises  from  the  greater  activity  of  their  circulation,  or  from  some 
difference  in  the  chemical  composition  of  the  blood.  The  respi- 
ration which  is  most  audible  to  the  ear,  is  not  that  which  pro-  ' 
duces  the  greatest  sound  in  the  interior  of  the  chest.  I  do  not 
here  allude  to  that  species  of  respiration  which  is  accompanied 
with  a  rattling  or  wheezing,  or  any  other  foreign  sound,  but  to 
that  kind  of  respiration  which  is  simply  loud,  and  which  is  so 
frequent  in  dyspnoea.  This  noise  is  merely  the  aggravation  of 
the  natural  sound  made  by  many  persons  in  sleep,  and  is  caused 
by  the  mode  in  which  the  air  impinges  upon  the  parts  in  the 
fauces.  We  can  imitate  it  at  will.  I  am  acquainted  with  an 
asthmatic  patient,  whose  habitual  respiration  can  be  heard  at  the 
distance  of  twenty  feet,  and  whose  respiration,  as  heard  in  the 

*The  clause  between  brackets  is  supplied  from  a  note  of  Dr.  M.  Laennec.  Dr. 
Williams  says,  he  has  remarked  the  sound  of  respiration  to  be  more  distinct  after 
meals. — (Rational  Exp.  p.  26.) — Translation. 


38-  EXPLORATION    OF 

interior  of  the  chest,  is,  nevertheless,  weaker  than  in  the  majority 
of  men.  The  same  remark  applies  to  the  noise  (snoring) 
emitted  by  many  healthy  persons  during  sleep ;  and,  also,  to  the 
imitative  sounds  of  jugglers  and  ventriloquists, — all  of  which  are 
produced  in  the  throat  and  posterior  nates,  and  arc  quite  -uncon- 
nected with  the  sound  of  respiration  in  the  interior  of  the  chest. 

When  we  can  distinctly  perceive,  and  with  a  uniform  intensity, 
the  respiratory  sound  in  every  part  of  the  chest,  we  may  be  as- 
sured that  there  exists  neither  effusion  into  the  cavity  of  the 
pleura,  nor  any  species  of  obstruction  in  the  substance  of  the 
lungs.  On  the  other  hand,  when  we  find  the  respiration  is  not 
to  be  distinguished  in  any  particular  point,  we  may  safely  con- 
clude that  the  corresponding  portion  of  the  lungs  within,  is  be- 
come impermeable  to  the  air  from  some  cause  or  other.  This 
sign  is  as  easy  to  be  perceived  as  the  presence  or  absence  of  the 
sound,  in  the  percussion  of  Avenbrugger,  and  affords  precisely 
the  same  indications.  With  the  exception  of  some  peculiar  cases, 
in  which  the  simultaneous  employment  of  the  two  different  me- 
thods gives  us  signs  which  are  completely  pathognomonic — we 
may  state  it  as  a  general  fact,  that  the  absence  of  the  sound  on 
percussion  coincides  uniformly  with  the  absence  of  respiration, 
as  ascertained  by  the  stethoscope.  Auscultation,  as  we  shall 
find,  has  this  advantage  over  percussion,  that  it  points  out  more 
correctly  the  various  degrees  of  pulmonary  obstruction.  It  has 
certainly  the  inconvenience  of  requiring  a  little  more  time  in  its 
application ;  but,  on  the  other  hand,  it  demands  less  care  and 
attention,  and  moreover  can  be  employed  in  all  cases,  even  in 
those  wherein  percussion  affords  no  results  whatever.* 

2.  Bronchial  respiration.  By  this  term  I  designate  the  sound 
of  respiration  as  observed  in  the  larynx,  trachea,  and  larger 
bronchial  trunks.  When  we  apply  the  stethoscope  upon  the 
larynx  or  cervical  portion  of  the  trachea,  we  perceive  that  the 
respiratory  sound  fs  without  that  slight  degree  of  crepitation 
which  accompanies  the  dilatation  of  the  air  cells  of  the  lun°-s : 
the  idea  of  a  drier  sound  seems  to  be  suggested  to  us,  and  we  at 
the  same  time  feel  distinctly  that  the  air  is  passing  through  a 
large  empty  space.     The   modification  of  the  respiratory  sound 

In  a  healthy  state  of  the  lungs,  the  respiratory  murmur  occurs,  and  is  hoard 
at  the  moment  the  air  enters  the  air-cells— the  expiration  of  the  air  is  attended 
by  a  very  feeble  sound,  or  more  commonly  by  none  at  all.  In  some  individuals 
however,  the  case  is  different,— and  the  sound  of  expiration  is  very  distinct—' 
sometimes  equalling— sometimes  exceeding,  and  sometimes  more  feeble  than 
that  of  inspiration. 

In  investigating  the  vesicular  respiration,  then,  two  sounds  require  our  attcn 
tion.     The  sound  we  first  hear  is  that  of  inspiration— and  the  second,  is  thai  of 
expiration.     We  shall   see  presently  that  the   latter  becomes  very  distinct   thai 
it  may  exceed  the  former  in  intensity,  and  entirely  mask  it  by  its  superior  mur- 
mur, in  certain  diseased  states  of  the  lungs.— .Vndral. 


THE    RESPIRATION.  '.]9 

may  be  perceived  over  the  greater  part  of  the  neck :  it  is  strongly 
marked  on  the  side  of  the  neck  ;  and  we  must  be  on  our  guard 
against  it  when  exploring  the  acromion  region,  insomuch  that  if 
we  direct  the  extremity  of  the  cylinder  towards  the  lower  portion 
of  the  neck,  we  run  the  risk  of  hearing  the  tracheal  respiration 
only,  and  may  thereby,  if  not  well  versed  in  the  distinctive  cha- 
racters of  the  different  kinds  of  respiration,  be  led  to  consider  the 
upper  lobes  as  quite  sound,  when  they  are  in  fact  altogether  im- 
permeable to  air.  When  a  person  inspires  strongly  by  the  nos- 
trils, a  like  sound,  originating  in  the  nasal  canal  and  fauces,  may 
be  heard  over  the  whole  surface  of  the  head.  In  certain  subjects, 
especially  if  very  lean,  the  respiration  possesses  somewhat  of  this 
character  when  examined  over  the  sternum  and  at  the  roots  of 
the  lungs,  that  is,  between  the  scapulae,  and  particularly  near 
their  upper  and  inner  angle  ;  but  here  the  bronchial  sound  is  not 
so  readily  distinguished,  because  of  its  intermixture  with  the 
common  respiratory  or  vesicular  murmur.*  Still  less  are  we  able, 
in  the  healthy  condition  of  the  lungs,  to  distinguish  this  peculiar 
modification  of  the  respiration  in  the  smaller  bronchial  tubes,  in 
other  points  of  the  chest.  When,  however,  the  texture  of  the 
lungs  becomes  indurated  or  condensed  from  any  cause,  such  as 
pleuritic  effusion,  or  the  changes  occasioned  by  a  severe  peri- 
pneumony  or  haemoptysis,  the  vesicular  respiration  having  then 
disappeared,  or  being  much  lessened,  we  can  frequently  perceive 
distinctly  the  bronchial  respiration,  not  only  in  the  large  but  even 
in  the  small  ramifications  of  the  bronchi.  In  such  cases,  although 
this  peculiar  modification  of  the  respiratory  sound  is  perceived 
in  other  parts,  still  it  is  nowhere  so  distinct  as  at  the  roots  of  the 
lungs.  Next  to  the  roots,  the  upper  lobes  exhibit  it  most  fre- 
quently ;  and  it  is  here,  as  we  shall  afterwards  find,  that  the 
bronchi  are  most  apt  to  become  dilated. f  The  cause  of  this  bron- 
chial respiration  appears  to  me  very  obvious :  in  fact,  when  the 
air  is  prevented  from  penetrating  the  cells,  this  is  the  only  kind 
of  respiration  that  can  exist ;  and  it  is  found  to  be  louder  and 
more  distinct  in  proportion  as  the  lung  is  more  condensed,  and 
thereby  becomes  a  better  conductor  of  sound. 

It  is  of  great  consequence  to  distinguish  accurately  the  bron- 
chial from  the  vesicular  or  pulmonary  respiration, J  not  only  on 

*  Considered  as  a  sign  of  disease,  bronchial  respiration  is  more  valuable  in 
proportion  as  it  is  perceived  at  a  distance  from  the  roots  of  the  lungs. — (M.  L.) 

t  I  think  that  something  more  than  a  mere  dilatation  of  the  bronchi  is  requi- 
site to  cause  the  true  bronchial  respiration.  To  produce  this  effect,  more  or 
less  of  the  pulmonary  parenchyma  must  become  impermeable  to  the  air. — Andral 

\  This  distinction  is  sufficiently  easy  in  the  adult,  but  much  less  so  in  infancy, 
on  account  of  the  intensity  of  the  vesicular  respiration.  Still,  the  bronchial  res- 
piration may  be  recognized  by  its  tubular  character, — that  is,  its  resemblance  to 
the  sound  produced  by  blowing  into  a  wooden  or  metallic  tube.— (M.  L.) 


40  EXPLORATION    OF    THE    VOICE. 

account  of  the  great  errors  of  diagnosis  which  must  result  from 
their  being  confounded,  but  because  the  former  becomes  a  pathog- 
nomonic sign  in  several  cases  of  importance.  In  peripneumony 
it  is  one  of  the  first  indications  of  hepatization,  and  commonly 
precedes  the  loss  of  the  natural  sound  on  percussion  :  it  is  like- 
wise one  of  the  earliest  signs  of  an  accumulation  of  tubercles  in 
the  upper  lobes  of  the  lungs. 

3.  Cavernous  respiration.  T  understand  by  this  term,  the 
sound  produced  by  inspiration  and  expiration  in  an  excavation 
formed  in  the  substance  of  the  lungs,  whether  arising  from  the 
softening  of  a  tubercle,  from  gangrene,  from  abscess,  [or  from  ex- 
tensive dilatation  of  the  bronchi.]  This  variety  has  the  same 
character  as  the  preceding,  only  that  it  further  conveys  the  idea 
of  air  entering  into  a  larger  cavity  than  a  bronchial  tube  :  and 
when  there  exists  any  doubt  as  to  this  being  really  the  case,  other 
circumstances  connected  with  the  sound  of  the  voice  and  cough, 
remove  all  uncertainty. 

4.  Blowing  or  puffing  respiration.  In  those  cases  wherein 
either  the  bronchial  or  cavernous  respiration  exists,  it  is  some- 
times observed  that  when  the  patient  is  breathing  quickly  and  by 
fits,  during  inspiration  the  air  appears  as  if  drawn  from  the  aus- 
cultatory ear,  while  in  expiration  it  seems  blown  into  it.  This 
species  of  respiration  is  one  of  those  phenomena  which  serve  to 
confirm  the  existence  of  an  excavation  near  the  surface  of  the 
lungs, — but  there  are  others  yet  more  precise  which  will  be  no- 
ticed hereafter.  This  sort  of  puffing  or  blowing  is  equally  pro- 
duced during  coughing  and  speaking.  The  illusion  of  blowing 
into  the  ear  in  these  cases  is  so  perfect,  that  it  is  only  from  the 
absence  of  the  feeling  of  titillation,  and  of  warmth  or  coldness, 
which  a  blast  of  air  so  impelled  must  necessarily  occasion,  that 
we  are  led  to  doubt  its  reality.  This  phenomenon  is  found  to 
take  place  equally  in  the  bronchi  which  adjoin  the  surface  of  the 
lungs,  and  particularly  in  the  large  branches  at  their  roots,  when 
the  substance  of  the  lung  around  is  condensed,  as  in  pneumonia, 
or  by  a  pleuritic  effusion,  In  the  case  of  excavations,  this  variety 
of  respiration  always  indicates  that  they  are  very  close  to  the 
surface  of  the  lungs.  It  sometimes  also  presents  a  further  modi- 
fication which  I  call  the  veiled  puff  {souffle  voile).  In  this  case, 
it  seems  to  us  as  if  every  vibration  of  the  voice,  cough,  or  respira- 
tion, agitates  a  sort  of  moveable  veil  interposed  between  the  ex- 
cavation of  the  ear.  This  particular  modification  obtains  under 
the  following  conditions  : — 1.  in  tuberculous  excavations  of  which 
the  walls  are  very  thin,  at  least  in  some  points,  and  which  are 
unconnected  by  adhesions  with  the  costal  pleura ;  2.  in  perip- 
neumonic  abscesses  of  which  the  walls  are  unequally  indurated, 
and  in  some  places  only  congested  ;  3.  in  cases  of  peripneumonv' 


THE    RESPIRATION.  41 

when  some  part  of  a  large  bronchial  ramification  passes  through 
a  portion  of  lung  still  sound  or  only  slightly  congested ;  4.  in 
dilatation  of  the  bronchi,  and  also  sometimes  in  pleurisy,  when 
the  affected  branch  has  some  part  much  less  dense  than  the 
rest.  We  must  be  careful  not  to  confound  this  phenomenon, 
with  a  variety  of  mucous  rhonchus  which  sometimes  accompa- 
nies it. 

Sect.  II.  Auscultation  of  the  voice. 

In  the  very  earliest  period  of  my  researches  on  mediate  aus- 
cultation, I  attempted  to  ascertain  the  differences  which  the 
sound  of  the  voice  within  the  chest  might  occasion.'  In  examin- 
ing several  subjects  with  this  view,  I  was  struck  with  the  disco- 
very of  a  very  singular  phenomenon.  In  the  case  of  a  woman, 
affected  with  a  slight  bilious  fever,  and  a  recent  cough  having 
the  character  of  a  pulmonary  catarrh,  on  applying  the  cylinder 
below  the  middle  of  the  right  clavicle,  while  she  was  speaking, 
her  voice  seemed  to  come  directly  from  the  chest,  and  to  reach 
the  ear  through  the  central  canal  of  the  instrument.  This  pecu- 
liar phenomenon  was  confined  to  a  space  about  an  inch  square, 
and  was  not  discoverable  in  any  other  part  of  the  chest.  Being 
ignorant  of  the  cause  of  the  singularity,  I  examined,  with  the 
view  to  its  elucidation,  the  greater  number  of  the  patients  in  the 
hospital,  and  I  found  it  in  about  twenty.  Almost  all  these 
were  consumptive  cases  in  an  advanced  stage  of  the  disease.  In 
some  the  existence  of  tubercles  was  still  doubtful,  though  there 
was  reason  to  suspect  them.  Two  or  three,  like  the  woman 
above  mentioned,  had  no  symptom  of  this  disease,  and  their  ro- 
bustness seemed  to  put  all  fears  of  it  out  of  the  question.  Not- 
withstanding this  I  began  immediately  to  suspect  that  this  phe- 
nomenon might  be  occasioned  by  the  tuberculous  excavations  in 
the  lungs.  The  observation  of  the  same  thing  in  patients  who  had  no 
other  symptoms  of  phthisis,  did  not  appear  to  me  conclusive  against 
the  correctness  of  my  suspicions,  because  I  knew  it  to  be  by  no 
means  unusual  to  find  in  the  lungs  of  persons  carried  off*  by  some 
acute  disease,  and  who  had  never  shown  any  sign  of  consump- 
tion, tubercles  not  only  softened  but  excavated,  and  forming  the 
very  case  denominated  the  ulceration  of  the  lungs.  The  subse- 
quent death,  in  the  hospital,  of  the  greater  number  of  the  individ- 
uals who  had  exhibited  this  phenomenon,  enabled  me  to  ascertain 
the  correctness  of  my  supposition  ;  in  every  case  I  found  excava- 
tions in  the  lungs  of  various  sizes,  the  consequence  of  the  dis- 
solution of  tubercles,  and  all  communicating  with  bronchial  tubes 
>l  variable  size. 
1  found  this  peculiar  phenomenon  (which  I  have  denominated 
6 


42  EXPLORATION    OF    THE    VOICE. 

Pectoriloquy)  to  be  more  perceptible  according  to  the  density  of 
the  walls  of  the  excavation  and  its  proximity  to  the  superhces 
of  the  lungs ;  and  that  it  was  most  striking  when  these  adhered 
to  the  pleura  in  such  a  manner  as  to  render  the  thoracic  parietes 
almost  a  part  of  the  walls  of  the  ulcerous  excavation, — a  case  of 
very  frequent  occurrence.    ' 

This  circumstance  naturally  led  me  to  think,  that  pectoriloquy 
is  occasioned  by  the  superior  vibration  produced  by  the  voice,  in 
parts  having  a  comparatively  more  solid  and  wider  extent  of  sur- 
face than  the  air  cells  and  small  bronchial  tubes ;  and  I  imagined 
that  if  this  were  so,  the  same  effect  ought  to  result  from  the  ap- 
plication of  the  cylinder  to  the  larynx  or  ttachea  of  a  person  in 
health.  My  Conjecture  proved  correct.  There  is  an  almost  per- 
fect identity  of  effect  between  pectoriloquy  and  the  sound  of  the 
voice  as  heard  through  the  tubes  resting  on  the  larynx  ;  and  this 
experiment  offers  an  excellent  means  for  giving  us  an  exact  no- 
tion of  the  phenomenon,  when  we  have  not  the  proper  subjects 
for  observation. 

The  sound  of  the  voice  in  the  different  parts  of  the  organs  of 
respiration,  and  in  the  different  conditions  of  these,  in  health  and 
in  disease,  offers  several  important  varieties  which  we  shall  now 
consider.*  In  a  healthy  lung  it  is  very  slight,  whether  examined 
by  the  naked  ear  or  stethoscope,  being  only  a  slight  vibration 
analogous  to  that  felt  on  applying  the  hand.  I  have  already 
noticed  the  character  of  the  voice  on  the  larynx  and  trachea :  it 
resounds  strongly,  traverses  the  tube  of  the  stethoscope,  and  pre- 
vents the  unarmed  ear  from  hearing  that  issuing  from  the  mouth. 
The  same  thing  takes  place  over  nearly  the  whole  lateral  surface 
of  the  neck,  and  even,  in  some  individuals,  towards  the  nape. 
On  this  account,  in  examining  the  acromion  region,  we  must  re- 
member the  precautions  stated  when  speaking  of  the  exploration 
of  the  respiration  in  the  same  place.  The  natural  resonance  of 
the  voice  in  the  throat  and  nasal  fossae,  is  perceptible,  more  or 
less,  over  the  whole  surface  of  the  head.  In  that  portion  of  the 
trachea  lying  beneath  the  sternum,  it  sounds  loudly  but  does  not 
traverse  the  tube ;  on  this  account  we  must  distrust  doubtful 
pectoriloquy  when  it  exists  only  about  the  upper  portion  of  the 
sternum. 

*  In  the  exploration  of  the  voice,  the  stethoscope  is  to  be  used  complete,  that 
is.  with  the  stopper  in  its  place,  the  instrument  being  pressed  with  considerable 
force  upon  the  chest,  while  the  ear  is  laid.-  lightly  on  the  other  extremity.  In 
the  case  of  pectoriloquy,  when  the  ear  is  pressed  loo  forcibly  upon  the  stetho- 
scope, the  voice  seems  to  remain  at  its  pectoral  extremity,  while,  on  the  contra- 
ry, it  completely  traverses  it  when  the,  pressure  is  slight.  Dr.  Meriadec  Laen- 
nec  from  whom  I  have  partly  taken  this  note,  says,  he  has  occasionally  heard 
perfect  pectoriloquy  at  some  distance  from  the  stethoscope,  when  he  was  an 
proaching  his  ear  to  the  instrument,  hut  had  not  reached  it.—  Trajisl. 


BRONCHOPHONY.  43 

Bronchophony.  The  sound  of  the  voice  is,  in  most  cases,  still 
more  obscure  in  the  larger  bronchial  trunks  at  the  roots  of  the 
lungs,  that  is,  in  the  interscapular  region :  nevertheless  it  is 
always  somewhat  louaer  in  this  place,  especially  about  the  up- 
per and  inner  angle  of  the  scapula,  than  in  the  other  parts  of  the 
chest.  It  is  indeed  very  rare  for  it  to  be  perceived  distinctly 
traversing  the  stethoscope,  in  a  perfectly  healthy  subject ;  but  it 
is  found  to  resound  so  loudly  at  its  extremity  as  to  be  more  rea- 
dily heard  through  the  instrument,  than  the  voice  issuing  from 
the  mouth  is  heard  by  the  other  ear.  In  persons,  however,  of  a 
delicate,  and  feeble  frame,  particularly  in  lean  children,  there  fre- 
quently exists  in  this  situation,  a  bronchophony  very  similar  to 
the  laryngophony  already  noticed. 

The  sound  of  the  voice  is  scarcely  at  all  perceptible  in  the 
bronchi  distributed  through  the  lungs,  when  these  organs  are 
healthy.  This  might  be  expected  a  priori,  since  the  loose  tex- 
ture of  the  lungs,  rendered  still  more  rare  by  its  intermixture 
with  air,  is  a  bad  conductor  of  sound ;  and  the  softness  of  the 
bronchial  branches,  after  they  cease  to  be  cartilaginous,  renders 
them  very  unfit  for  its  production  ;  while  the  smallness  of  their 
calibre  must  render  whatever  sound  is  produced  more  acute  and 
weaker  in  them  than  in  the  larger  trunks.  But  if  any  one  of 
these  adverse  conditions  is  removed,  and  yet  more,  if  several  of 
them  are  so  at  the  same  time,  the  sound  of  the  voice  may  become 
perceptible  in  the  smaller  bronchial  tubes.  Accordingly  it  is 
found  that  an  attack  of  peripneumony,  an  extensive  hemoptysi- 
cal  induration,  or  the  accumulation  of  a  great  number  of  tuber- 
cles in  the  same  point,  by  condensing  the  texture  of  the  lungs, 
gives  occasion  to  a  sound  analogous  to  pectoriloquy.  This  phe- 
nomenon, which  I  denominate  accidental  bronchophony,  is,  as 
might  be  expected,  most  marked  when  the  pulmonary  indura- 
tion has  place  near  the  roots  of  the  lungs.  This  sign  is  one  of 
those  which  serve  best  to  measure  the  progress  of  a  recent  perip- 
neumony. 

The  dilatation  of  the  bronchi  gives  rise  to  the  same  phenome- 
non, and  the  more  readily,  because  the  substance  of  the  lungs  in 
the  neighborhood  of  the  dilated  branches,  is  often  more  compact 
than  in  the  natural  state.  Sometimes  two  of  the  causes  mention- 
ed conspire  to  produce  it ;  for  instance,  the  cause  just  mentioned, 
and  the  accumulation  of  tubercles. 

Bronchophony  is  rarely  so  like  pectoriloquy  as  to  deceive  a 
person  even  of  moderate  experience.  In  the  former,  the  voice 
merely  traverses  the  cylinder ;  its  tone  is  somewhat  like  that  of 
a  speaking  trumpet ;  and  the  sound  is  more  diffused  in  its  seat 
than  pectoriloquy.  Where  any  doubt  exists,  this  is  removed  by 
the  cough  and  the  character  of  the  respiration  in  the  same  point: 


44  EXPLORATION    OF    THE    VOICE. 

neither  of  these  lias  the  cavernous  character :  we  feel  assured 
that  the  whole  phenomena  have  for  their  site  a  series  of  tubes 
and  not  a  circumscribed  space.* 

Pectoriloquy.  This  phenomenon  may  be"  produced  under  very 
different  circumstances:  1.  by  the  softening  of  tubercles  (by  far 
the  most  common  cause)  ;  2.  "by  the  decomposition  of  a  gangre- 
nous eschar  ;  3.  by  an  abscess,  the  consequence  of  peripneumony  ; 
4.  by  the  evacuation  of  a  cyst  into  the  bronchi ;  and  probably 
also  by  a  fistulous  communication  between  the  bronchi  and  an  ab- 
scess of  the  mediastinum. 

Pectoriloquy  offers  great  varieties,  in  respect  of  intensity  and 
completeness.     I  divide  it  into  perfect,  imperfect  or  doubtful. 

Pectoriloquy  is  perfect  when  the  transmission  of  the  voice 
through  the  stethoscope  is  complete,  and  when  it,  as  well  as  the 
corresponding  results  obtained  from  the  exploration  of  the  cough 
and  ronchus,  are  exactly  circumscribed :  in  this  case  it  can 
never  be  confounded  with  bronchophony.  It  is  imperfect,  when 
some  one  of  those  characteristics  is  wanting,  and  particularly  if 
the  transmission  of  the  voice  be  not  evident.  It  is  doubtful, 
when  the  sound  of  the  voice  is  very  feeble,  and  when  it  can  be 
distinguished  from  bronchophony  only  by  the  aid  of  other  signs 
derived  from  the  consideration  of  its  site,  the  general  symptoms, 
and  the  progress  of  the  disease.  These  last  circumstances  suffice, 
in  almost  every  case,  to  enable  us  to  distinguish  the  nature  of  the 
excavation. 

The  circumstances  which  concur  to  render  pectoriloquy  per- 
fect are — the  complete  emptiness  of  the  excavation,  the  increased 
density  of  the  portion  of  lung  which  forms  its  walls,  its  ready 
communication  with  one  or  more  bronchial  tubes  of  a  considera- 
ble size,  and  its  proximity  to  the  walls  of  the  chest.  It  is  pro- 
per to  state,  however,  that  whatever  be  the  distance  of  the  cavity 
from  the  surface  of  the  lungs,  if  it  possesses  the  other  qualities 
indicated,  it  will  always  yield  perfect  pectoriloquy,  unless,  in- 
deed, a  very  considerable  thickness  of  healthy  lung  be  inter- 
posed, which,  owing  to  its  defective  density,  is  necessarily  a  bad 
conductor  of  sound.  The  extent  of  the  excavation  contributes 
also  to  the  completeness  of  the  phenomenon  :  it  is  most  distinct 
when  this  is  somewhat  considerable :  it  is  however  often  com- 
plete when  the  cavity  is  very  small.  On  the  other  hand,  pecto- 
riloquy is  sometimes  very  indistinct    where  the  excavations  are 

*  Bronchophony  (that  is,  accidental  or  rmorbid  bronchophony — Tr.)  may  exist 
in  any  point  of  the  walls  of  the  chest;  but  owing  to  the  vicinity  of  the  large 
bronchial  trunks  and  to  the  greater  frequency  of  hepatization  of  the  pulmonary 
substance  in  the  inferior  lobes,  it  is  found  most  frequently  between  the  scapula' 
and  over  the  infra-spinous  portion  of  these  hones.  It  is  also  observed  pretty 
frequently  m  the  axilla  and  below  the  clavicles,  in  consequence  of  the  "reatei 
prevalence  ol  tubercles  in  the  upper  lobes. — (M.  L.) 


iEGOPHONY.  45 

very  large,  the  size  of  the  fist,  for  instance,  and  when  they  com- 
municate with  the  bronchi  by  small  openings.*  It  has  several 
limes  been  manifest  to  me,  that  when  the  number  of  fistulous 
openings,  by  which  a-  very  large  excavation  communicates  with 
the  bronchia,  increases,  pectoriloquy  becomes  less  evident,  or 
ceases  altogether.  It  disappears  also  in  the  two  following  cases : 
viz.  when  an  excavation  opens  into  the  pleura,  particularly  if  the 
opening  is  large  and  direct ;  and  when  its  contents  make  their 
way  through  the  walls  of  the  chest  into  the  cellular  membrane 
outside.  Pectoriloquy  may  likewise  be  sometimes  suspended  for 
several  hours,  and  even  days,  by  the  temporary  obstruction  of 
the  communication  of  the  cavity  with  the  bronchi,  by  the  matter 
contained  in  it.  We  shall  hereafter  point  out  the  method  of 
obtaining  pectoriloquy,  or  other  equivalent  signs,  in  cases  of  this 
kind.f 

JEgophony.  The  phenomenon  to  which  I  have  applied  this 
name,  is,  of  all  those  furnished  by  auscultation,  that  which 
seems  to  me  most  complex  in  its  causes.  It  may  readily  be  con- 
founded, by  the  inexperienced,  with  pectoriloquy  ;  and  still  more 
so  with  bronchophony.  I  was  myself  long  guilty  of  this  mis- 
take ;  and  although  the  distinction  is  easy  when  the  respective 
characters  of  each  are  strongly  marked,  there  occur  cases  in 
which  this  is  hardly  practicable.  My  uncertainty  as  to  the  na- 
ture of  aegophony  was  of  longer  duration,  because  it  does  not 
exist  in  every  case  of  pleurisy ;  because  the  analogous  phenome- 
non of  bronchophony  is  still  more  frequently  wanting  in  perip- 
neumony  ;  because  these  two  diseases  and  consequently  the  two 
phenomena  in  question  are  frequently  combined  ;  and,  finally, 
because  the  number  of  fatal  cases  of  these  diseases,  more  parti- 
cularly of  acute  pleurisy,  is  too  inconsiderable  to  afford  many  op- 
portunities of  verifying,  by  examination  after  death,  the  accuracy 
of  the  diagnosis  derived  from  auscultation.J 

Simple  aegophony  consists  in  a  peculiar  sound  of  the  voice 
which  accompanies  or  follows  the  articulation  of  words  ;  it  seems 
as  if  a  kind  of  silvery  voice,  of  a  sharper  and  shriller  tone  tha/i 
that  of  the  patient,  was  vibrating  on  the  surface  of  the  lungs, 
sounding  more  like  the  echo   of  the  voice  than  the  voice  itself. 

*This  fact  may  bo  explained  on  the  principles  of  acoustics,  and  by  a  refer- 
ence to  certain  musical  instruments. — Author. 

t  Pectoriloquy  may  be  observed  on  any  part  of  the  thorax,  as  morbid  excava- 
tions may  occur  in  any  part  of  the  lungs;  but  as  these  excavations  are  most  com- 
monly produced  by  the  evacuation  of  the  matter  of  tubercles,  and  as  tubercles 
.ire  principally  developed  in  the  upper  lobes,  it  is  below  the  clavicles  and  in 
the  axilla  that  we  ought  to  expect  to  meet  with  it  most  frequently. —  (M.  L.) 

\  This  assertion  may  seem  strange  to  thepractitioners  who  employ  only  bleed- 
ing and  blisters  in  those  diseases,  but  will  be  confirmed  by  the  young  physi- 
cians ; i ii*1  students  who  have  attended  my  Cliniquc  since  I  have  been  in  the  hab- 
it of  using  Tartar  Emetic  m  large  doses. — Author 


46  EXPLORATION    OF    THE    VOICE. 

It  rarely  appears  to  enter  the  tube  of  the  instrument,  and  scarcely 
ever  passes  through  it  entirely.  It  has,  moreover,  another  char- 
acter, so  constant  as  to  lead  me  to  derive  from  it  the  appellation 
of  the  phenomenon, — I  mean  a  trembling  or  bleating  sound  like 
the  voice  of  a  goat,  a  character  which  is  the  more  strikin g  be- 
cause the  key  or  tone  of  it  approaches  that  of  this  animal's  voice.* 
When  aegophony  exists  in  the  vicinity  of  a  large  bronchial  trunk, 
particularly  towards  the  root  of  the  lungs,  it  is  frequently  com- 
bined with  more  or  less  of  bronchophony.  The  reunion  of  these 
affords  numerous  varieties,  of  which  we  may  have  a  good  idea 
by  recollecting  the  following  phenomena:  1.  the  sound  of  the 
voice  through  a  metallic  speaking  trumpet'  or  cleft  reed  ;  2.  that 
of  a  person  speaking  with  a  counter  between  his  lips  and  teeth  ; 
3.  the  nasal  intonations  of  the  juggler  speaking  in  the  character 
of  Punch.  This  last  comparison  is  frequently  the  most  exact 
imaginable,  particularly  in  persons  whose  voice  is  somewhat  bass 
(grave.)  Very  commonly,  the  same  individuals  who  exhibit  at 
the  roots  of  the  lungs,  this  combination  of  the  two  phenomena, 
yield  simple  aegophony,  about  the  outer  and  .lower  edge  of  the 
scapula. 

The  sort  of  bleating  so  characteristic  of  aegophony  seems,  in 
most  cases,  immediately  connected  with  the  articulation  of  the 
words,  although  the  patient's  true  voice  has  nothing  of  the  sort : 
sometimes,  however,  it  seems  unconnected  with  the  articulation, 
so  that  we  can  hear,  at  the  same  time,  yet  separately,  the  sim- 
ple sound  of  the  voice  and  the  bleating  silvery  sound  of  aego- 
phony ;  which  last  appears  to  be  either  nearer  or  more  remote 
than  the  resonance  of  the  simple  voice.  Sometimes,  even,  when 
the  patient  speaks  slowly  and  interruptedly,  we  hear  trie  bleat- 
ing, like  an  imperfect  echo,  immediately  after  the  voice.  These 
two  last-named  varieties  have  appeared  to  me  to  exist  only  in 
cases  of  slight  effusion.  To  hear  this  sound  properly,  we  must 
apply  the  cylinder  strongly  to  the  patient's  chest,  and  place  the 
ear  gently  on  the  other  end.  If  the  latter  is  forcibly  applied, 
Hje  bleating  sound  is  diminished  one-half,  and  the  phenomenon 
approaches  nearer  to  bronchophony. 

In  comparing  the  results  of  my  early  and  more  recent  experi- 
ence respecting  aegophony,  it  seems  to  me  certain  that  it  exists 
only  in  cases  of  pleurisy,  either  acute  or  chronic,  attended  by  a 
moderate  effusion  in  the  pleura,  or  in  hydrothorax  or  other  liquid 
extravasation  in  the  same  cavity. 

All  the  cases  in  which'  I  have  observed  aegophony,  since  I 
have  been  able  to  discriminate  it  from  pectoriloquy  and  broncho- 

*  The  word  JEgophony  is  derived  from  d|  (atyos)  a  front,  and  <j>uvr,,  voice.  In 
exploring  the  chest  for  it,  the  stethoscope  is  to  be  used  as  directed  in  the  note 
on  Pectoriloquy,  p.  42. —  Transl. 


JEG0PH0NY.  47 

phony,  have,  at  the  same  time,  afforded  other  undoubted  signs 
of  effusion  into  the  chest.  In  the  examples  of  pleurisy  which  I 
have  been  able  to  attend,  to  from  their  commencement  to  their 
close,  I  found  it  as  early  as  the  first  hours  of  the  attack  ;  but  it 
has  never  been  observed  strongly  marked  until  the  second,  third, 
or  fourth  day,  and  hardly  ever  until  after  the  sound  of  respira- 
tion has  become  almost  or  altogether  imperceptible  in  the  affect- 
ed side,  and  until  this  has  yielded  the  dull  sound  on  percussion. 
1  have  observed  segophony  in  every  case  of  pleurisy  which  has 
come  under  my  care  during  the  last  five  years,  except  in  a  few 
very  slight  acute  cases,  where  the  effusion  (as  proved  by  the 
auscultation  of  the  respiration  and  by  percussion)  was  inconsider- 
able, and  in  those  which  did  not  come  under  my  notice  until  far 
advanced  and  when  they  were  in  progress  towards  recovery.  I 
have  discovered  this  sign  in  cases  where  there  did  not  exist  above 
three  or  four  ounces  of  fluid  in  the  chest.  iEgophony  decreases 
and  gradually  disappears  as  the  effusion  is  absorbed.  In  very 
acute  cases,  it  exists  frequently  two  or  three  days  only,  and  then 
totally  disappears :  in  the  chronic  state  of  the  disease  with  mo- 
derate effusion,  I  have  found  it  sometimes  continue  for  several 
months,  with  variations  of  intensity  proportioned  to  the  varying 
quantity  of  the  effused  fluid.  When  this  is  very  great,  particu- 
larly when  it  is  sufficient  to  cause  dilatation  of  the  chest,  aego- 
phony  ceases  entirely.  I  have  never  observed  it  in  old  cases  of 
empyema  in  which  the*lungs  were  compressed  upon  the  medias- 
tinum :  but  have  detected  it,  in  an  imperfect  degree,  in  certain 
cases  where  the  pleura  contained  from  two  to  three  pints  of  pus, 
and  where  the  lungs  were  prevented  from  being  quite  removed 
from  the  side  by  previous  adhesions.  On  the  other  hand,  I  have 
found  that  those  cases,  which,  when  first  seen,  presented  all  the 
otiier  signs  of  copious  effusion  except  aegophony,  yielded  this  sign 
also  when  the  dilatation  of  the  side  diminished,  and  the  other 
symptoms  indicated  the  partial  absorption  of  the  fluid.  In  two 
cases  of  empyema  operated  on  by  my  direction  in  1821  and  1822, 
aegophony  became  much  more  manifest  after  the  escape  of  a  por- 
tion of  the  pus. 

iEgophony  is  not,  like  pectoriloquy,  confined  to  one  point,  but 
extends  over  a  certain  continuous  portion  of  the  chest.  Most 
frequently  it  exists,  at  the  same  time,  over  the  whole  space 
between  the  scapula  and  spine,  round  the  lower  angle  of  the 
former  bone,  and  in  a  zone  from  one  to  three  fingers  broad, 
following  the  line  of  the  ribs  from  its  middle  to  the  nipple.  This 
portion  of  the  chest  evidently  corresponds  with  the  internal  parts 
where  the  effused  fluid  forms  a  thin  layer  on  the  surface  of  the 
lungs ;  it  being  well  known  that,  in  cases  of  modern  extravasa- 
tion, the  fluid  collects  principally  in  the  lower  part  of  the  chest, 


48  EXPLORATION    OP    THE    VOICE. 

when  the  patient  is  seated  or  resting  on  the  back ;  and  that,  even 
in  the  cases  where  the  whole  surface  of  the  lung  is  covered  by 
it,  the  thickness  of  the  layer  progressively  diminishes  from  below 
upwards,  and  is  always  much  less  before  than  behind.  In  a  very 
few  instances  I  have  detected  segophony,  at  the  commencement 
of  the  disease,  over  the  whole  affected  side  ;  in  two  of  these  I 
ascertained,  by  examination  after  death,  that  this  peculiarity  de- 
pended upon  the  retention  of  the  lung  in  partial  apposition  with 
the  chest,  by  means  of  pretty  numerous  adhesions,  so  that  the 
lung  became  invested  by  a  thin  layer  of  fluid  over  its  whole  sur- 
face. In  cases  of  this  kind  the  sign  in  question  is  observable 
during  the  whole  period  of  the  disease. 

I  consider  segophony  to  be  owing  to  the  natural  resonance  of 
the  voice  in  the  bronchial  tubes,  rendered  more  distinct  by  the 
compression  of  the  pulmonary  texture,  and  by  its  transmission 
through  a  thin  layer  of  fluid  in  a  state  of  vibration.  This 
opinion  is  supported  by  many  facts  and  reasons.  The  points 
where  it  is  constantly  found,  correspond  with  the  upper  border  of 
the  fluid,  and  where  it  is  of  least  thickness.  Moreover,  if  the 
patient  turns  on  his  face,  the  sound  either  disappears  or  is 
greatly  diminished  between  the  scapula  and  spine,  while  it  con- 
tinues on  the  side ;  and  if  he  turns  on  the  healthy  side,  the  same 
result  is  obtained  in  the  diseased  side,  now  the  uppermost.*  In 
respect  of  the  influence  of  change  of  position  upon  this  pheno- 
menon, I  have  observed  that  the  change«was  much  less  in  cases 
where  the  quantity  of  fluid  was  either  somewhat  above  or  below 
the  mean,  than  when  it  was  of  middling  extent.  The  places 
formerly  mentioned  as  yielding  most  distinct  segophony,  are 
those  where  the  bronchial  tubes  are  the  largest  and  most  nume- 
rous. This  tends  to  confirm  the  truth  of  the  opinion  above 
stated,  as  well  as  the  fact  of  the  cessation  of  the  sign  when  the 
effusion  becomes  very  copious,  and  its  return  on  this  being 
diminished :  in  the  former  case,  it  is  evident  that  the  bronchi,  as 

*  M.  Reynaud,  one  of  Laenncc's  most  zealous  disciples,  lias  ascertained,  that 
if  an  aegophonous  patient  lies  on  his  belly,  or  leans  forward  so  as  to  bring  the 
body  into  an  almost  horizontal  position,  not  only  does  the  segophony  disappear 
from  the  interscapular  region,  but  is  replaced  by  a  bronchophony  of  a  greater  or 
less  intensity  according  as  the  lung  is  sound  or  in  a  state  of  inflammation.  In 
the  latter  case,  as  the  segophony  vanishes,  the  crepitous  rhonchus, or  the  bron- 
chial respiration,  reappears.  From  this,  M.  Reynaud  infers,  that  eegophony  is 
merely  a  remote  bronchophony,  that  is  to  say,  a  bronchophony  heard  through  a 
layer  of  fluid,  of  greater  or  less  thickness.  (Journ.  hebdom.  de  Med.  Dec.  J.-"!::).) 
It  is,  however,  of  little  consequence  what  may  be  the  actual  nature  of  segopho- 
ny, providedit  be  ascertained  that  it  depends  on  an  anatomical  condition  of 
parts  (lilferent  from  thai  which  gives  occasion  to  bronchophony  properly  so  called 
And  M.  Raynaud's  observation  establishes  this  fact  beyond  all  question  and 
moreover,  supplies  us  with  the  means  of  distinguishing,  in  every  case  aegopho- 
ny  from  simple  bronchophony,  and  consequently  pleurisy  or  pleuro-pncumonia 
from,  simple  pneumonia. — (M.  L.) 


AEGOPHONY.  49 

well  as  the  lungs,  must  be  compressed,  while  in  the  latter,  they 
must  be  the  first  to  recover  their  natural  shape  on  account  Of  their 
superior  elasticity.  The  following  circumstance,  which  I  have 
now  and  then  observed,  leads  to  the  same  conclusion.  In  cases 
where  aegophony  was  very  strongly  marked  in  the  zone  formerly 
mentioned,  and  where  auscultation  of  the  respiration,  percussion, 
and  the  general  symptoms  clearly  indicated  an  effusion,  I  have 
remarked  from  day  to  day  the  following  changes  take  place  in 
respect  of  this  sign,  and  precisely  at  the  same  moment  that  the 
other  signs  just  enumerated  gave  evidence  of  the  progressive 
absorption  of  the  fluid  :  it  had  become  less  loud  every  where ; — it 
had  lost  three  inches  in  extent,  reckoning  from  above  downwards, 
in  the  interscapular  region,  and  one  inch  oo  the  side,  and  had 
entirely  disappeared  in  front ;  while,  on  the  other  hand,  it  had 
become  very  distinct  though  not  loud,  over  the  whole  inferior 
parts  of  the  side  and  back,  where  it  did  not  exist  at  all  on  the 
preceding  day.  These  changes,  I  think,  indicated  the  recession 
of  the  fluid  from  the  upper  parts,  and  its  diminution  in  the  lower. 
In  fact,  I  am  of  opinion,  that  this  phenomenon  only  exists  when 
the  lung  is  enveloped  with  a  thin  layer  of  fluid  ;  and  that  in  the 
instances  just  mentioned  it  became  perceptible  on  the  lower  parts 
of  the  chest,  only  because  the  quantity  of  this  had  diminished. 
This  opinion  is  further  rendered  probable  by  the  fact  of  the 
respiration  being  always  very  distinct  in  the  places  where  aego- 
phony exists,  while  it  is  not  observed  at  all  or  very  feebly  below 
these  places ;  and,  by  the  additional  observation,  that  when  the 
aegophony  descends,  as  above  mentioned,  the  respiration  becomes 
stronger  in  the  points  which  it  leaves,  and  re-appears  in  those 
which  it  now  occupies.  I  have  already  stated,  that  in  cases  of 
very  copious  effusion,  there  is  usually  no  aegophony,  or  if  it 
exists  at  all,  it  is  only  near  the  roots  of  the  lungs,  a  situation 
where  the  fluid  is  necessarily  less  than  any  where  else. 

It  will  be  difficult  to  fix  more  precisely  than  I  have  now 
endeavored  to  do,  the  exact  relation  between  the  bronchi  and 
the  thoracic  effusion,  which  gives  rise  to  aegophony.  This  will 
be  the  more  difficult  on  account  of  the  small  number  of  cases 
that  prove  fatal  during  the  existence  of  this  phenomenon. 
When  death  occurs  from  pleurisy  the  effusion  is  generally  very 
abundant,  and  aegophony  has  therefore  disappeared.  In  looking 
for  assistance  from  morbid  anatomy,  in  this  instance,  we  are, 
therefore,  reduced  to  the  very  small  number  of  cases  that  prove 
fatal  from  some  concomitant  disease,  at  the  very  time  when  the 
patients  happened  to  be  affected  with  pleurisy  in  that  stage 
wherein  aegophony  exists. 

I  made  an  experiment  with  the  view  to  ascertain  the  effect  of 
an  interposed  fluid  in  modifying  the  voice  to  the  character  it 
7 


50  EXPLORATION    OF    THE    VOICE. 

possesses  in  oegophonv,  bv  applying  a  bladder,  hall  filled  with 
water,  between  the  scapul  of  a  young  man  who  presented  a  well- 
marked  natural  bronchophony  in  this  point.  In  this  case,  it 
appeared  to  myself  and  several  persons  present,  that  the  voice, 
as  transmitted  through  the  liquid,  became  more  acute,  and  also 
slightly  tremulous,  although  less  decidedly  so  than  in  real  aego- 
phony.  The  same  experiment  tried  over  the  larynx  gives  a 
similar  result. 

It  seems  probable  that  the  compression  of  the  bronchial  tubes 
by  the  pleuritic  effusion  contributes  a  good  deal  to  the  production 
of  this  phenomenon ;  since  this  must  bring  them  into  a  form 
analogous  to  the  reeds  of  certain  wind  instruments,  such  as  the 
oboe  and  bassoon,  which  have  something  of  the  bleating  sound 
of  segophony.  This  alteration  of  form,  however,  will  not  of 
itself  account  for  the  phenomenon,  without  the  presence  of  fluid, 
else  it  would  exist  in  cases  of  contraction  of  the  chest  subsequent 
to  pleurisy,  which  is  not  the  fact.  It  would  also  be  found  in 
many  cases  of  phthisis,  wherein  tubercles  frequently  compress 
the  bronchi  in  the  most  decided  manner.* 

I  think  there  are  only  three  cases  of  pleurisy  in  which  this 
phenomenon  will  not  be  observed:  these  are, — 1.  where  a  very 
rapid  and  copious  effusion  has  suddenly  compressed  the  lung 
against  the  mediastinum  ; — 2.  where  a  former  attack  of  the  same 
disease  has  firmly  attached  the  posterior  parts  of  the  lung  to  the 
pleura ;  and  3.  where  there  is  hardly  any  liquid  extravasation, 
but  the  formation,  simply,  of  false  membranes.  This  last  case 
is  very  rare ;  and  besides  I  have. found  aegophony  where  not  more 
than  two  or  three  ounces  of  fluid  existed. 

From  the  preceding  observations,  I  think  we  are  entitled  to 
conclude  that  segophony  is  a  favorable  sign  in  pleurisy,  as  it 
seems  uniformly  to  indicate  a  moderate  degree  of  effusion.  Its 
continuance  for  some  time  is  a  favorable  omen,  as  showing  that 
the  effusion  does  not  increase  :  if  it  continues  as  long  as  the 
fever,  or  longer,  we  may  be  assured  that  the  disease  will  not 
become  chronic,  as  this  never  happens  except  when  the  effusion 
is  extremely  abundant.     I  have  frequently  drawn  this  prognostic, 

*  Dr.  Williams  says,  that  this  additional  explanation  of  the  cause  of  aegopho- 
ny is  not  only  unnecessary,  but  untenable.  "  The  reed  of  the  bassoon  and  haut- 
boy," he  observes,  "  sounds  only  on  the  passage  of  air  through  it,  and  did  the 
flattened  bronchi  represent  it  in  this  instance,  the  respiration,  and  not  the  voice, 
should  make  the  sound."  In  accordance  with  the  previous  explanation  of  our 
author,  Dr.  W.  says,  "  the  tremulous  or  subsultory  sound  of  the  eegophonic  voice 
is  produced  by  successive  undulations  of  the  liquid,  the  result  of  an  irregular 
transmission  of  the  sonorous  vibrations."  The  same  author  savs,  that  in  addi- 
tion to  the  preceding  requisites,  there  must  likewise  exist  a  certain  proportion  be- 
tween the  mass  of  liquid  and  the  pitch  and  strength  of  the  vocal  sounds,  other- 
wise the  fluid  will  not  be  thrown  into  vibration.     This,  he  says,  is  proved'  bv  the 

fact,  that  certain  tones  of  the  same  voice  are  eegophonic,  and  others  not Rat 

Expos,  p.  107.  ti.—  Transl. 


iEGOPHONY.  51 

and  haVe  never  been  deceived  in  it.  In  every  case  where  I  have 
seen  apute  pleurisy  terminate  in  chronic,  this  phenomenon  has 
ceased,  or  been  much  lessened,  previously  to  the  decrease  of  the 
febrile  symptoms. 

iEgophony,  like  pectoriloquy,  is  sometimes  suspended  for  a 
longer  or  shorter  time,  re-appearing  after  the  patient  has  coughed 
or  expectorated.  But  this  happens  much  less  frequently  in  the 
case  of  the  former,  as  might  be  expected  from  the  comparatively 
small  bronchial  secretion  in  pleurisy. 

Some  physicians  have  lately  fancied  that  they  have  met  with 
aegophony  in  cases  of  simple  peripneumony  without  any  pleuritic 
effusion  ;  but  I  have  no  doubt  they  mistook  bronchophony  for  it. 
It  must  be  admitted  that  the  two  phenomena  are  likely  to  be 
confounded ;  I  shall,  therefore,  in  this  place,  compare  them  with 
each  other,  as  well  as  with  pectoriloquy.  1.  Pectoriloquy  being, 
in  the  great  majority  of  cases,  owing  to  the  presence  of  tubercu- 
lous excavations,  is  almost  always  met  with  in  the  upper  lobes. 
In  whatsoever  part,  however,  it  may  exist,  it  will  always  be 
readily  distinguished  by  the  accompanying  cavernous  rhonchus, 
respiration  and  cough.  In  certain  rare  instances,  namely,  where 
the  excavation  is  of  a  flattened  shape  with  rather  solid  walls, 
pectoriloquy  may  assume  something  of  the  vibratory  character  of 
aegophony  ;  but  it  will  almost  always  be  distinguished  from  it, 
by  the  exact  circumscription  of  the  sound  to  a  small  space,  by  its 
situation,  and  by  the  consideration  of  the  accompanying  pheno- 
mena. 2.  Bronchophony  being  caused  by  the  simple  induration 
of  the  substance  of  the  lungs,  does  not  yield  the  clear  transmis- 
sion of  the  voice  through  the  tube,  except  at  the  roots  of  the 
lungs.  The  sphere  of  this  phenomenon  is  always  ovei^a  certain 
extent,  and  no  one  small  point  can  be  said  to  be  its  exclusive  site. 
The  same  is  true  of  the  respiration  and  cough  ;  the  former  is 
frequently  found  to  be  bronchial,  and  the  latter  to  give  'the 
mucous  rhonchus,  but  they  are  diffused  over  a  certain  space,  and 
not,  like  those  which  are  observed  in  cases  of  pectoriloquy,  con- 
fined within  a  circumscribed  spot.  Bronchophony  is  less  readily 
suspended  than  pectoriloquy,  but  more  frequently  than  aegophony, 
for  obvious  reasons  depending  on  the  relative  condition  of  the 
bronchial  secretion  in  the  diseases  in  which  each  especially  occurs. 
Finally,  the  tone  or  key  of  the  speaking  trumpet  completes  the 
list  of  the  distinctive  characters  of  bronchophony.  3.  True  and 
simple  aegophony  is  characterised  by  the  harsh  tremulous  silvery 
tones  of  the  voice,  which  is  commonly  more  acute  than  the  na- 
tural voice  of  the  patient,  and  seems  to  be  quite  superficial,  and 
to  float,  as  it  were,  on  the  surface  of  the  lungs,  instead  of  coming 
from  the  interior,  like  pectoriloquy  and  bronchophony.  It  seems, 
moreover,  to  be  rather  the  echo  of  the  voice,  repeating  the  words 


52  EXPLORATION    OF    TI^E    VOICE. 

or  their  final  syllables,  in  a  small  sharp  and  tremulous  key,  than 
the  voice  itself.  This  character  of  aegophony  is  especially,  mark- 
ed when  it  exists  in  the  anterior  and  lateral  parts  of  the  chest ; 
since  between  the  scapulae  and  at  their  lower  edge  (to  which 
situation,  by  the  way,  it  is  most  commonly  restricted)  it  is  almost 
always  conjoined  with  the  natural  bronchophony,  rendered 
stronger  by  the  compression  of  the  lungs  in  that  part.  And  it  is 
here,  in  the  space  between  the  inner  edge  of  the  scapula  and  the 
spine,  and  in  this  part  only,  that  we  occasionally  perceive  the 
bleating,  aegophonic  voice  completely  traversing  the  tube,  with 
the  most  perfect  resemblance  of  the  squeaking  of  Punch. 
iEgophony  and  bronchophony  are  necessarily  conjoined  in  cases 
of  pleuro-peripneumony ;  and,  indeed,  pectoriloquy  may  co-exist 
with  them,  when  an  abscess  of  the  lung  supervenes. 

When  I  published  the  first  edition  of  this  work,  I  was  not 
quite  sure  that  segophony  might  not  exist  in  simple  peripneu- 
mony ;  farther  experience,  however,  has  completely  convinced 
me  that  this  cannot  be  the  case.  Whatever  analogy  there  may 
be  between  this  phenomenon  and  bronchophony  it  is  easy  to 
distinguish  them,  when  they  exist  separately  ;  and  an  experienced 
ear  may  recognise  them,  in  most  cases,  when  they  co-exist  in 
pleuro-peripneumony.  Certain  cases,  however,  will  always  be 
doubtful ;  and  when  it  is  so,  we  must  be  contented  with  the 
portion  that  is  certain.  The  following  positions  seem  proved : 
1.  that  aegophony  exists  in  simple  pleurisy,  and  in  no  case  with 
more  decided  characters :  2.  that  bronchophony  exists  frequently 
in  peripneumony,  and  with  features  sufficiently  well  marked  to 
distinguish  it  from  aegophony ;  3.  that  both  these  co-exist  in 
certain  c%ses  of  pleuro-peripneumony. 

When  we  meet  with  cases,  where  the  results  obtained  from 
percussion  and  the  auscultation  of  the  respiration  leave  reason  to 
doubt  as  to  the  existence  of  pleurisy  or  peripneumony,  if  we  find 
aegophony  very  complete  and  little  mixed  with  bronchophony, 
we  may  conclude  that  the  disease  is  exclusively  the  former,  or 
nearly  so;  and,  on  the  other  hand,  if  the  bronchophony  is 
strongly  marked,  and  with  merely  a  shade  of  the  stuttering 
cracked  note  of  aegophony,  we  may  decide  upon  peripneumony 
being  the  chief  disease,  conjoined,  probably,  with  a  slight  pleu- 
ritic effusion.  We  may  even  conclude  against  the  existence  of 
any  effusion,  if  the  characteristics  of  aegophony  are  observed 
only  at  the  inner  border  of  the  scapula.* 

I  have  dwelt  the  longer  upon   these  distinctions  because  they 

.  *  tA11  t,h«Lse  diagnostic  signs  will  be  much  more  certain  if  we  examine  the  na- 
tient  in  different  positions.  Decubitus  on  the  abdomen  will,  i„  „Sa ^ena- 
ble us _  to  distinguish  simple  Aphony  from  simple  bronc'hophon  or  from 
bronchophony  conjoined  with  aegophony.  (see  note,  p.  48.)  (jtf  L  )      ' 


JEGOPHONY.  53 

form  perhaps  the  most  difficult  point  in  auscultation,  and  particu- 
larly because  segophony  is  the  only  one  among  the  stethoscopic 
signs,  whose  value  has  been  called  in  question*  by  competent 
judges.  Cases  of  simple  peripneumony,  in  which  segophony  was 
supposed  to  exist,  have  been  communicated  to  me  by  several  of 
my  colleagues,  and  by  many  pupils.  All  these,  as  far  as  I  had 
the  means  of  ascertaining,  were  examples  of  bronchophony  mis- 
taken for  segophony,  or  a  mixture  of  the  two.  In  like  manner 
I  am  constantly  meeting  with  cases  in  the  hospital,  where  the 
two  phenomena  are  confounded  by  the  pupils ; — but  when  I 
have  pointed  out  the  distinction  between  them,  and  they  have 
acquired  more  experience,  they  hesitate  only  in  cases  which  are 
really  doubtful. 

Sect.  III.  Auscultation  of  the  cough. 

Coughing  in  a  healthy  state  of  the  lungs  excites  no  particular 
sound  within  the  chest.  When  we  listen  with  the  cylinder  on 
the  larynx  or  trachea,  and  at  the  roots  of  the  lungs  where  the 
chest  is  narrow,  besides  the  shock  communicated  by  the  act  of 
coughing,  we  hear,  at  the  same  time,  a  sound  as  of  the  transmis- 
sion of  air  in  a  tube.  When  the  lungs  are  inflamed  to  the  degree 
of  hepatization,  tiiis  peculiar  sound  becomes  more  manifest,  at 
the. root  of  the  lungs,  and  even  in  the  bronchial  tubes,  not  larger 
than  a  goose-quill,  than  it  is  in  the  trachea  in  a  state  of  health  ; 
I  therefore  shall  designate  it  tubary  cough.-f  This  cough  is 
found  also  in  cases  of  pleurisy,  but  at  the  roots  of  the  lungs 
only.  It  exists  equally  in  cases  of  dilatation  of  the  bronchi,  and 
may  serve  as  a  test  of  the  degree  of  dilatation.  Where  there 
exists  an  excavation  in  the  lungs  communicating  with  the 
bronchi,  the  cough  resounds  in  it  as  it  does  in  the  larynx,  but 
is  confined  to  a  small  space :  it  also  gives  rise  to  the  cavernous 
rhonchus,  and  more  readily  than  simple  respiration  does,  parti- 
cularly if  there  is  still  much  matter  contained  in  it,  and  not  in  a 
very  liquid  state.  If  the  excavation  is  empty,  this  emptiness  is 
indicated  by  the  cavernous  cough,  better  than  any  other  pheno- 
menon. Coughing  gives  also,  in  certain  cases,  the  metallic 
tinkling,  when  it  is  not  perceptible  by  the  respiration  or  voice. 
When  pectoriloquy  is  suspended  in  a  tuberculous  excavation, 
from  obstruction  of  the  bronchi  by  the  sputa,  coughing  restores 
it  by  the  expulsion  of  these,  or  excites  the  cavernous  rhonchus, 

*  A  curious  misprint  exists  in  this  passage,  in  the  new  edition  of  the  original, 
viz.— of  cOnstatie  for  contestee,  whereby  the  author  is  made  to  assert  directly 
the  reverse  of  what  he  intends. —  Transl. 

t  I  consider  the  term  bronchial  cough  employed  by  Andral  (Diet,  de  Med 
Prat,  t  iii.  p.  662)  decidedly  preferable  to  that  in  the  text.—  Transl. 


54  EXPLORATION    OF    THE    VOICE. 

which  is  of  the  same  import  as  a  diagnostic  sign :  it  clears,  in 
like  manner,  the  fistulous  communications  between  the  pleura 
and  bronchi.  In  the  excavations,  where  the  tuberculous  matter 
has  only  begun  to  be  softened,  and  in  the  incipient  abscess  of 
peripneumony,  while  simple  respiration  is  still  unable  to  excite 
any  rhonchus,  coughing  will  often  give  a  very  strong  guggling. 
And  it  may  be  stated  as  a  general  truth,  that  all  the  sounds  to 
be  described  in  the  next  Section,  are  more  audible  during  the 
act  of  coughing  than  during  simple  respiration.  However,  in 
deducing  our  indications  from  the  auscultation  of  the  cough, 
certain  precautions  are  necessary.  Sometimes  a  violent  cough 
seems  rather  to  close  than  open  the  pulmonary  channels,  produc- 
ing a  great  commotion  of  the  lungs  and  walls  of  the  thorax 
without  giving  rise  to  any  guggling.  At  other  times,  in  timid 
patients,  the  cough  seems  confined  to  the  throat,  and  excites  no 
resonance  in  the  bronchi.*  One  of  the  cases  where  this  inten- 
tional cough  is  most  useful,  is  in  that  variety  of  the  dry  catarrh, 
wherein  the  respiratory  sound  is  inaudible  under  ordinary  cir- 
cumstances. Here  the  act  of  coughing,  which,  as  we  have 
formerly  observed,  is  always  either  preceded  or  followed  by  a 
powerful  inspiration,  enables  us  to  hear  the  sound  of  respiration, 
and  thereby  to  judge  of  the  condition  of  the  lungs.  The  same 
measure  is  equally  valuable  in  incipient  peripneumony,  especially 
if  drafted  on  a  chronic  dry  catarrh.  In  this  case,  percussion 
elicits  a  sound  which  is  either  doubtful  or  delusive,  and  common 
respiration  is  inaudible;  but  the  cough  restores  the  respiratory 
murmur,  whenever  the  lungs  are  permeable,  and  enables  us  to 
detect  the  crepitous  rhonchus,  the  pathognomonic  sign  of  inci- 
pient peripneumony. 

It  is  proper  to  observe,  that  we  ought  not  to  have  recourse  to 
the  factitious  cough,  as  a  means  of  exploration,  except  where 
simple  respiration  is  insufficient,  as  it  may  fatigue  our  patients. 
At  the  same  time,  I  may  add,  that  its  inconveniences,  in  this 
respect,  are  less  than  may  be  imagined  ;  as  one  single  cough,  and 
that  rather  moderate  than  otherwise,  is  sufficient  to  afford  to  an 
experienced  observer  all  the  signs  which  this  phenomenon  is 
capable  of  yielding. 

Sect.  IV.  Auscultation  of   sounds  not  necessarily  accompa- 
nying the  respiration  and  voice. 

Various  sounds,  foreign  to  the  natural  respiratory  murmur  or 
resonance  of  the  voice,  may  arise  within  the  chest  from  various 

*  In  this  latter  case  we  desire  the  patient  to  cough  after  taking  a  rWn  msni- 
ratjon. — Author.  n        '  <        r 


OF    THE    RHONCHUS.  55 

accidental  causes.:    I  shall  class  these    under    two    heads — the 
rhonchus  and  metallic  tinkling. 

1 .   Of  the  different  kinds  of  rhonchus. 

For  want  of  a  better  or  more  generic  term  I  use  the  word 
rhonchus*  to  express  all  the  sounds,  besides  those  of  health, 
which  the  act  of  respiration  gives  rise  to,  from  the  passage  of  the 
air  through  fluids  in  the  bronchi  or  lungs,  or  by  its  transmission 
through  any  of  the  air  passages  partially  contracted.  These 
sounds  likewise  accompany  the  cough,  and  are  made  even  more 
perceptible  by  it ;  but  in  most  cases,  the  auscultation  of  the 
respiration  suffices  for  their  exploration.  They  are  extremely 
various ;  and  although  they  possess,  in  general,  very  striking 
characters,  it  becomes  difficult'  so  to  describe  them  as  to  convey 
any  thing  like  a  correct  notion  to  those  who  have  never  heard 
them.  Sensations,  we  know,  can  only  be  communicated  to 
others  by  comparisons  ;  and  although  those  which  I  shall 
employ  may  seem  to  myself  sufficiently  exact,  they  may  not  be 
so  to  others.  I  expect,  however,  that  my  description  will  enable 
any  observer  of  ordinary  application,  to  recognise  them  when  he 
meets  with  them,  as  they  are  much  more  easily  distinguished 
than  described. 

We  can  distinguish  five  principal  kinds  of  rhonchi :  1.  the 
moist  crepitous  rhonchus,  or  crepitation ;  2.  the  mucous  rhon- 
chus, or  guggling  ;  3.  the  dry  sonorous  rhonchus,  or  snoring ; 
4.  the  dry  sibilous  rhonchus,  or  whistling  ;  5.  the  dry  crepitous 
rhonchus,  with  large  bubbles,  or  crackling.f 

*  It  is  very  desirable  that  some  name  might  be  found  for  this  phenomenon 
which  would  prove  generally  acceptable  to  British  physicians.  In  the  former 
edition  of  this  translation,  the  nearest  English  synonyme,  rattle,  was  used,  but 
this  word  has  been  adopted  by  few.  The  original  French  term  rale  appears  to 
be  most  generally  employed  in  this  country;  but  there  are  several  objections  to 
its  use.  In  the  present  work  I  shall  give  the  preference  to  the  Latin  synonyme, 
rhonchus,  also  employed  by  Laennec  and  sanctioned  by  the  adoption  of  Dr. 
Williams  and  Dr.  Copland. —  Tr. 

t  The  different  kinds  of  rhonchi  have  their  site  either  in  the  air  cells,  or 
bronchial  tubes,  or  in  some  morbid  excavations  formed  in  the  substance  of  the 
lungs  ;  and  they  are  caused  either  by  some  substance  within  these,  more  or  less 
fluid,  and  moving  in  contact  with  air,  or^  by  some  other  obstruction  in  the  air 
passages  from  external  compression  or  alteration  of  their  coats.  A  consideration 
of  these  different  causes,  and  of  the  sounds  resulting  from  them,  seems  to  point 
out  a  very  convenient  mode  of  arranging  them  as  follows  :— 1.  Rhonchi  having 
their  site  in  the  vesicles  or  air  cells— vesicular  rhonchi;  2.  Rhonchi  having  their 
site  in  the  bronchial  tubes— bronchial  rhonchi ;  3.  Rhonchi  having  their  site  in 
morbid  excavations — cave/mous  rhonchi.  All  the  causes  of  these  sounds  may 
be  divided  into  two  kinds,  according  as  they  are  dependent  on  the  presence  of 
a  liquid,  or  on  some  change  in  the  coats  or  caliber  of  the  air  passages,  or  on 
obstruction  from  matter*of  a  solid  kind.  The  different  kinds  of  rhonchi  may 
therefore  be  termed  either  humid  or  dry.  We  shall  thus  have  our  classification 
as  follows  : — 


56  THE    MUCOUS    RHONCHUS. 

I .  The  moist  crepitous  rhonchus*  has  evidently  its  site  in  the 
substance  of  the  lungs.  It  resembles  the  sound  produced  by  the 
crepitation  of  salts  in  a  tessel  exposed  to  a  gentle  heat,  or  that 
produced  by  blowing  into  a  dried  bladder,  or  it  is  still  more  like 
that  emitted  by  the  healthy  lungs  when  distended  by  air  and 
compressed  in  the  hand, — only  stronger.!  Besides  the  sound  of 
crepitation,  a  sensation  of  humidity  in  the  part  is  clearly  con- 
veyed. We  feel  that  the  pulmonary  cells  contain  a  watery 
fluid  as  well  as  air,  and  that  the  intermixture  of  the  two  fluids 
produces  bubbles  of  extreme  minuteness. 

This  species  of  rhonchus  is  one  of  the  most  important,  and 
fortunately  it  is  most  easily  distinguished ;  a  single  observation 
being  sufficient  to  mark  it  ever  after.  It  is  the  pathognomonic 
sign  of  the  first  stage  of  peripneumony,  disappearing  on  the 
supervention  of  hepatization,  and  re-appearing  with  the  resolution 
of  the  inflammation.  It  is  found  also  in  oedema  of  the  lungs, 
and  sometimes  in  pulmonary  apoplexy,  but  in  these  two  cases, 
the  bubbles  usually  seem  to  be  somewhat  larger  and  moister  than 
in  the  rhonchus  of  peripneumony.  This  variety  I  call  subcrep- 
itous.% 

I. —  Vesicular  rhonchi. 

1.  Humid  vesicular  rhonchus— Moist  crepitous  rhonchus— Rale  crepitant  of 
Laennec.  , 

2.  Dry  vesicular  rhonchus— Dry  crepitous  rhonchus— Rale  crepitant  sec  a 
grosses  bulles,  ou  craquement  of  Laennec. 

II. — Bronchial  rhonchi. 

1.  Humid  bronchial  rhonchus — Mucous  rhonchus — Rale  muqueux  of  Laennec. 

2.  Dry  bronchial  rhonchus.  a.  Sibilous  rhonchus— Rale  sibilant  sec  of  La- 
ennec.    b.  Sonorous  rhonchus  Rale  sonore  sec  of  Laennec. 

III. — Cavernous  rhonchi. 

1.  Humid  cavernous  rhonchus— Cavernous  rhonchus— Gargouillement,  Rale 
caverneux  of  Laennec. 

2.  Dry  cavernous  rhonchus.  This  species  is  added  more  on  account  of  uni- 
formity, and  because  it  is  possible,  than  because  such  a  variety  has  been  des- 
cribed. 

*  Humid  vesicular  rhonchus. —  Transl. 

I  This  variety  of  rhonchus  is  compared  by  Andral  to  the  sound  produced  in 
rubbing  a  piece  of  parchment;  by  Dr.  Williams  to  the  sound  produced  in  rub- 
bing between  the  finger  and  thumb  a  lock  of  hair,  close  to  the  ear  Other  com- 
parisons have  been  adduced,  such  as  the  noise  of  boiling  butter,  that  occasioned 
by  the  bursting  of  the  minute  bubbles  on  the  surface  of  beer  or  soda  water  &c 
Of  these  the  comparison  of  Dr.  Williams  comes  nearest  the  natural  sound 
Perhaps  as  just  a  notion  of  it  may  be  conveyed  to  the  taind  bj  imagining  the 
quality  of  roughness  superadded  to  the  pure  or  smooth  sound  of  healthv  resDi- 
ration. — frans.  -         v 

X  M.  Cruveilhier  calls  in  question  the  propriety  of  considering  the  crepitous 
rhonchus  as  a  sign  of  pneumonia,  oedema  of  the  lungs  or  pulmonary  apoplexy 
pretending  that  it  may  be  wanting  in  these  diseases,  and  be  presenl  in  others'  of 
a  different  kind.  (Revue  Med.  Fev.  1830.)  It  seems  probable  from  this,  that  M 
Cruveilhier  is  unable  to  distinguish  the  true  crepitous  rhonchus  from  the  obscure 
mucous  rhonchus.— (M.  L.)  ouscure 

There  is  reason  in  M.  Cruveilhier's  objection,  since,  the  crepitous  rhonchus 
■  s  certainly  occasionally  perceptible  in  bronchitis,  and,  according  to  Dr.  Stoke" 
(Irish  Trans,  vol.  v.  p.  326,)  in  the  early  stage  of  phthisifi  ^OKes, 

In  a  late  work  on  Auscultation,  by  Mr.  Spittal,  (a  Treatise  on  Auscultation 


THE  TRACHEAL  RHONCHUS.  57 

2.  The  mucous  rhonchus.*  This  is  produced  by  the  passage 
of  the  air  through  sputa  accumulated  in  the  bronchi,  or  through 
the  softened  matter  of  tubercles  yet  undischarged.  It  presents 
many  varieties  of  character,  which  can  hardly  be  defined,  and  of 
which  indeed  we  can  only  form  any  notion,  by  comparing  the 
perceptions  derived  from  the  sense  of  hearing,  with  such  as  we 
fancy  might  be  conveyed  by  the  sense  of  sight.  In  listening  to 
it,  we  receive  the  impression  or  idea  of  bubbles,  such  as  are  pro- 
duced by  blowing  through  a  pipe  into  soapy  water.  The  ear 
seems  to  appreciate  most  distinctly  the  consistence  of  the  fluid 
which  forms  the  bubbles,  and  also  their  varying  sizes.  The  con- 
sistence of  the  fluid  appears  always  greater  in  the  mucous  than 
in  the  crepitous  rhonchus. 

In  respect  of  the  size  of  the  bubbles  in  the  different  rhonchi, 
they  may  be  estimated  as  very  large,  large,  middling,  small. 
The  last  term  is  especially  applicable  to  the  crepitous  rhonchus 
of  pertpneumony,  in  which  it  seems  as  if  an  infinity  of  minute 
equal-sized  bubbles,  formed  at  once,  were  thrilling  or  vibrating, 
rather  than  boiling,  on  the  surface  of  a  fluid.  The  mucous  rhon- 
chus, on  the  contrary,  appears  always  larger,  and  most  usually  un- 
equal, so  as  to  convey  the  idea  of  a  liquid  into  which  some  one  is 
blowing,  and  there*by  producing  bubbles,  of  which  some  are  of  the 
size  of  a  filbert  and  others  only  as  large  as  a  cherry-stone  or 
hempseed.  We  can  estimate  the  quantity  as  well  as  the  size  of 
the  bubbles,  and  may  thus  designate  the  rhonchus  as  abundant,  or 
rare.  Accordingly,  it  sometimes  seems  that  the  point  of  lung 
beneath  the  stethoscope,  is  filled  with  bubbles  that  touch  each 
other  ;  and  at  other  times,  there  seems  to  be  only  one  here 
and  there,  while  the  intervening  portion  of  lung  yields  the  simple 
sound  of  respiration,  or  yields  no  sound  at  all,  as  the  case  may 
be.  When  the  mucous  rhonchus  is  very  large  and  infrequent, 
we  can  distinctly  perceive  the  bubbles  form  and  burst.  When  it 
exists  at  once  copious,  large,  and  constant,  it  is  sometimes  so 
noisy  as  to  resemble  the  rolling  of  a  drum. 

A  variety  of  the  mucous,  is  the  tracheal  rhonchus.  It  is  ob- 
served, when  there  is  accumulated  much  mucous  or  other  sputa 
in  the  larynx,  trachea,  or  larger  bronchial  tubes,  and  may  be 
readily  heard  by  the  unassisted  car ;  as  in  the  case  of  the  dead- 
rattles  of  the  vulgar,  from  which  I  have  derived  the  general  ap- 
pellation of  the  phenomenon.     This  species,  or  rather  variety, 

by  Robert  Spittal,  Edin.,  1830,)  some  account  is  given  of  the  sounds  produced 
by  the  bursting  of  bubbles  on  the  surface  of  different  fluids  when  agitated.  He 
found  that  fluids  of  the  density  and  tenacity  of  s.erum  gave  rise  to  sounds  most 
nearly  resembling  those  of  the  moist  crepitous  rhonchus;  and  M.  Piorry  states, 
that  the  very  same  sound  is  produced  in  the  dead  body  by  injecting  fluids  into 
fhe  lungs.  (Du  Procede  Operatorne.  pp.  81,  94.) — Trans. 
'  Humid  bronchial  rhonchus — Trans- 

8 


58  THE    MUCOUS    RHONCHUS. 

may  exist  without  there  being  any  other  perceived  in  the  bronchi 
by  the  stethoscope ;  but  the  reverse  of  this  is  much  more  com- 
mon, namely,  that  the  instrument  conveys  to  us  a  rhonchus,  even 
a  very  loud  one,  when  we  perceive  nothing  by  the  unassisted  ear. 
When  examined  by  the  cylinder,  this  rhonchus,  which  has  its 
seat  in  the  trachea,  has  almost  always  the  character  of  the  mucous 
rhonchus  described  above.  The  bubbles  seem  to  be  extremely 
numerous  and  very  large.  The  sound  is  occasionally  so  loud  as 
to  resemble  a  drum,  or  the  noise  of  a  carriage  on  the  pavement. 
In  these  cases  the  rhonchus  is  perceived  over  the  whole  sternum, 
and  is  accompanied  by  a  vibration  very  perceptible. to  the  touch  : 
we  can  even  sometimes  perceive  it  over  the  whole  chest  and 
through  the  interposed  lung.  In  this  last  case,  however,  there  is 
no  vibration  attending  it;  and  we  recognize,  at  once,  that  the 
sound  originates  in  a  remote  point.  This  variety  of  rhonchus  is 
sometimes  so  noisy  as  to  mask  the  sound  of  the  heart's  action, 
and  also  of  respiration,  over  a  great  portion  of  the  chest ;  a"nd  in 
all  cases  where  it  exists  in  a  certain  degree  of  intensity,  we  are 
unable  to  perceive  the  heart's  pulsations  under  the  sternum, 
unless  we  request  the  patient  to  suspend  respiration  for  a  moment. 

The  tracheal  rhonchus  is  only  observed  in  this  great  degree, 
in  violent  haemoptysis,  and  in  the  severer  'paroxysms  of  the 
mucous  catarrh  of  old  persons  termed  suffocative  catarrh.  It  is 
found  in  most  dying  .persons,  particularly  in  cases  of  phthisis, 
peripneumony,  diseases  of  the  heart,  and  severe  idiopathic  fevers. 
In  all  cases,  when  it  exists  in  a  high  degree,  it  may  be  regarded 
as  of  evil  omen.  In  a  lesser  degree,  it  exists  in  the  acute  pulmo- 
nary catarrh,  in  the  severe  cases  of  the  chronic  mucous  catarrh, 
and  in  all  diseases  complicated  with  these.  It  may  be  reckoned 
as  one  of  the  worst  symptoms  which  appear  in  fever.  In  conclu- 
ding this  notice  of  the  tracheal  rhonchus,  it  ought  to  be  observed 
that  when  too  slight  to  be  heard  by  the  naked  ear,  it  becomes  very 
manifest  on  applying  the  stethoscope. 

The  mucous  rhonchus,  properly  so  called,  exists  principally  in 
the  pulmonary  catarrh  with  copious  secretion  of  mucus,  and  in 
haemoptysis ;  and  often  also  in  peripneumony  and  phthisis.  In 
the  two  former  diseases,  it  is  caused  by  the  transmission  ef  air 
through  the  mucus  or  blood  contained  in  the  bronchi ;  in  the 
two  latter,  it  may  have  its  seat  in  the  same  place,  but  it  may 
also  originate  in  cavities  produced  by  an  abscess  or  eschar  of 
the  lungs,  or  by  softened  tubercles.  In  the  latter  cases  the  rhon- 
chus has  a  peculiar  character  which  I  shall  denominate  cavernous  ■ 
it  is  more  than  usually  abundant  and  large,  and  is  confined  also 
to  a  small  space,  within  which  we  commonly  observe,  at  the  same 
tune,  both  the  cavernous  respiration  and  pectoriloquism  It  is 
more  especially  during  the  act  of  coughing  that  we  detect  this 


THE    MUCOUS    RHONCHUS.  Oy 

circumscribed  or  cavernous  rhonchus.  On  some  occasions,  Ave 
can  even  distinguish  the  consistence  of  the  fluid  contained  in  the 
excavation,  by  means  of  the  particular  impulse  communicated  by 
the  cough.* 

In  certain  rare  instances  the  mucous  rhonchus  may  be  recog- 
nized, or  at  least  suspected,  independently  of  auscultation,  either 
mediate  or  immediate.  I  have  sometimes  noticed,  while  percuss- 
ing the  clavicle  or  neighboring  parts  of  the  chest,  in  phthisical 
cases,  a  sort  of  vibration  like  that  yielded  by  a  cracked  pot  when 
gently  struck,  accompanied  with  an  evident  hollow  resonance, 
and  even  with  a  humid  crepitation  or  guggling.  The  phenome- 
non indicates  the  presence  of  tuberculous  excavations  near  the 
surface  of  the  lungs.  It  is,  however,  by  no  means  common,  and 
has  only  been  observed  in  subjects  with  very  thin  elastic  chests, 
and  (perhaps)  with  the  clavicular  ligaments  more  than  usually 
lax.f  Some  of  these  patients  are  themselves  conscious  of  the 
guggling  of  the  tuberculous  matter,  during  percussion  ;  and 
others  can  point  out  the  seat  of  the  excavation,  from  the  sensa- 
tion occasioned  by  the  detachment  of  the  sputa  from  it  during 
expectoration.  This  last  circumstance  is,  however,  very  uncom- 
mon. 

I  have  sometimes  also  perceived  in  tuberculous  excavations  of 
the  upper  lobes,  a  mucous  rhonchus,  or  slight  guggling,  corres- 

*  The  cavernous  rhonchi.  This  variety  deserves  a  more  distinct  notice  than 
Laennec  has  given  it.  All  the  other  rhonchi,  although  depending  on  a  morbid 
condition  of  the  part  in  which  they  originate,  still  have  their  site  in  cavities 
naturally  existing  in  the  state  of  health :  the  cavernous  rhonchus  is  in  every 
respect  morbid — in  its  site  as  well  as  its  cause.  It  may  exist,  as  stated  in  the 
text,  in  all  cases  whore  there  is  a  morbid  excavation  in  the  lungs  containing  a 
fluid,  and  communicating  with  the  bronchi ;  as  in  circumscribed  abscess,  and  in 
local  gangrene  of  the  lungs,  and  in  the  latter  stages  of  tubercle.  The  last 
named  is  by  far  the  most  usual  source  of  this  sign,  insomuch  that  I  doubt  if  it 
arises  once  in  a  hundred  times  from  any  other  cause.  It  is  characterized  by  a 
strongly  marked  mucous  rhonchus  or  guggling,  confined  to  a  small  spot,  instead 
of  being  diffused  over  a  considerable  portion  of  the  lung,  as  is  usually  the  case 
with  the  common  humid  bronchial  rhonchus.  It  is  particularly  heard  upon  the 
patient  taking  a  deep  inspiration,  or  after  coughing;  and  if,  under  such  circum- 
stances, it  is  very  strongly  marked,  continues  fixed  in  the  same  point,  and  is  not 
heard  in  any  other,  it  is  one  of  the  surest  signs  of  tuberculous  excavation,  even 
without  pectoriloquy  and  the  cavernous  respiration,  which  will  generally  be 
perceptible  in  the  same  point.  Andral,  a  high  authority,  considers  this  circum- 
scribed bubbling  rhonchus,  when  well  marked,  as  the  very  surest  sign  of  tuber- 
culous cavity. —  Trims! . 

t  This  sigh  has  been  noticed  somewhat  in  detail  by  M.  Martinet  in  the  Revue 
Med.  torn.  ii.  1824,  p.  253.  It  was  previously  pointed  out  by  Laennec  in  his  first 
edit.  torn.  ii.  p.  64,  and  was  known  to  him,  he  says,  as  early  as  1816.  He  says 
he  has  not  met  with  it  more  than  twenty  or  thirty  times  in  all.  According  to 
him.it  may  be  readily  confounded  with  the  jingling  of  a  metallic  ornament  worn 
on  the  brea'st,  such  as  a  loose  jointed-cross,  for  instance.  In  phthisical  subjects,  in 
whom  it  usually  occurs,  it  is  found  by  far  more  distinct,  if  we  percuss  while  they 
are  speaking  It  is  also  found,  but  rarely,  in  cases  of  dilated  bronchi.  Andral 
has  observe,:  this  sign  in  three  cases  only.  In  all  these  it  correctly  indicated 
the  existence  of  a  tuberculous  cavity.     Clin.  Med.  torn.  iii.  p.  65.—  Transl 


60  THE    SONOROUS    RHONCHUS. 

ponding  with,  and  no  doubt  caused  by,  the  pulsation  of  the  sub- 
clavian artery.  This  case  is  extremely  rare,  as  indeed  it  must  be, 
when  we  consider  the  numerous  circumstances  that  must  conspire 
towards  its  production.  In  an  equally  rare  class  of  cases,  a  strong 
mucous  or  cavernous  rhonchus  can  sometimes  be  perceived  by 
the  naked  ear,  or  on  applying  the  hand  to  the  part.  I  do  not 
here  allude  to  the  guggling  rhonchus  of  the  trachea  or  the  bron- 
chi, already  noticed,  but  to  one  confined  to  a  small  space,  and 
this  often  at  a  distance  from  the  larger  bronchial  tubes.  I  have 
observed  this  phenomenon  only  in  cases  where  the  matter  of  an 
excavation  had  made  its  way  through  the  walls  of  the  chest,  and 
formed  a  tumor  beneath  the  skin  ;  or  where  it  had  escaped  into 
old  cellular  adhesions  uniting  the  lungs  to  thetchest ;  or,  finally, 
where  a  large  anfractuous  excavation,  half  full  of  matter,  lay 
near  the  surface  of  a  lung  closely  united  to  the  walls  of  the 
chest.* 

3.  The  dry  sonorous  rhonchus.]  This  is  more  variable  in  its 
character  than  the  two  preceding  kinds.  It  consists  in  a  flat 
(grave)  sound,  sometimes  extremely  loud,  resembling  at  times 
the  snoring  of  a  person  asleep,  at  other  times  the  sound  produced 
by  friction  on  a  bass  string,  and  occasionally  the  cooing  of  the 
wood-pidgeon.  This  resemblance  is  sometimes  so  striking,  that 
we  might  be  tempted  to  believe  the  bird  concealed  under  the 
patient's  bed.  This  last  variety  of  sound  is  commonly  confined 
to  a  small  space.  I  have  sometimes  observed  it  in  cases  of  pul- 
monary fistulae  of  a  middling  size,  and  also  in  cases  of  dilated 
bronchi.  I  apprehend  it  can  hardly  exist  in  bronchial  tubes  of 
a  small  diameter.  We  must  not  confound  the  sonorous  rhonchus 
with  the  guttural  sounds  formerly  mentioned,  (p.  37,)  which,  un- 
like this,  have  their  seat  in  the  fauces,  as  may  be  ascertained  by 
the  application  of  the  stethoscope. 

It  is  difficult  to  ascertain  the  precise  cause  of  this  species  of 
rhonchus.  Neither  the  character  of  the  sound,  nor  the  examina- 
tion of  the  parts  after  death,  leads  to  the  belief  that  it  depends 
on  the  passage  of  the  breath  through  any  kind  of  matter.  On 
the  contrary,  it  would  seem  to  depend  rather  on  some  alteration 
in  the  shape  of  the  tubes  through  which  the  *air  passes,  and  I  am 
disposed  to  attribute  it  in  most  cases  to  the  contraction,  from 
some  cause  or  other,  of  the  origin  of  the  bronchial  branch.  This 
contraction  may  be  either  permanent  or  temporary,  and  may  be 

*  Sometimes  when  the  sound  of  respiration  is  suspended  or  very  weak,  the 
bubbles  of  the  njucous  rhonchus  become  very  small,  few  in  number,  and  not  per- 
ceptible, except  on  a  deep  inspiration  :  at  other  times,  when  the  respiration  is 
pretty  good,  it  is  found  not  to  be  pure  or  clear.  An  inexperienced  auscultator 
might  be  apt  to  confound  these  varieties  (which  may  be  named  obscure)  with  a 
weak  crepitous  rhonchus. — Author. 

t  Dry  bronchial  rhonchus. —  Transl. 


THE    SIBILOUS    RHONCHUS.  61 

occasioned  by  the  pressure  of  an  enlarged  gland,  or  of  a  circum- 
scribed spot  of  inflammation,  the  presence  of  a  tenacious  clot  of 
mucus,  or  the  local  thickening  of  the  mucous  membrane.  It 
may  not  be  easy  on  these  grounds  to  explain  the  reason  of  the 
key  of  the  sound  being  flatter  instead  of  sharper,  as  might  be  ex- 
pected from  the  contraction  of  the  aperture  ;  but  we  have  an  anal- 
ogous case  in  the  thickening  of  the  membrane  of  the  larynx  and 
glottis  in  catarrh,  when  the  voice,  as  we  know,  becomes  hoarser 
and  flatter  than  natural.* 

4.  The  dry  sibilous  rhonchus.  This  is  also  of  very  various 
character.  Sometimes  it  is  like  a  prolonged  whistle,  flat  or  sharp, 
dull  or  loud  ;  sometimes  it's  very  momentary,  and  resembles  the 
chirping  of  birds,  the  sound  emitted  by  suddenly  separating  two 
portions  of  smooth  oiled  stone,  or  by  the  action  of  a  small  valve. 
The  different  kinds  often  exist  together  in  different  parts  of  the 
lungs,  or  successively  in  the  same  part.  The  peculiar  nature  of 
the  sound,  and  the  appearances  on  dissection  seem  to  prove  the 
sibilant  rattle  to  be  owing  to  minute  portions  of  very  vicid  mu- 
cus obstructing,  more  or  less  completely,  the  small  bronchial 
ramifications.  This  explanation  applies  more  especially  to  the 
variety  resembling  the  sound  of  a  valve,  which  is  indeed  only  a 
variety  of  the  mucous  rhonchus  :  the  kind  more  strictly  sibilous, 
is  probably  occasioned  rather  by  a  local  contraction  of  the  smaller 
bronchi,  from  thickening  of  their  inner  membrane. 

5.  The  dry  crepitous  rhonchus  with  large  bubbles.^  This 
species  is  observed  only  during  inspiration.  It  conveys  the  im- 
pression as  of  air  entering  and  distending  lungs  which  had  been 
dried — and  of  which  the  cells  had  been  very  unequally  dilated 
— and  entirely  resembles  the  sound  produced  by  blowing  into  a 
dried  bladder. 

This  variety  is  the  pathognomonic  sign  of  emphysema  of  the 
pulmonary  substance,  and  of  the  interlobular  emphysema.  In  the 
last  disease  it  is  much  more  distinct.  We  have  a  sound  like 
this  in  the  common  sub-cutaneous  emphysema,  on  pressing  in- 
terruptedly with  the  ear  on  the  stethoscope,  or  with  the  fingers, 
in  the  vicinity  of  the  affected  part. 

Besides  the  peculiar  sound  produced  by  the  various  species  of 
rhonchus,  there  is  also  to  be  noticed  a  slight  vibration  communi- 
cated to  the  cylinder  when  the  seat  of  the  phenomenon  happens 
to  be  immediately  beneath  it.  This  sensation,  like  that  occa- 
sioned by  the  voice,  (p.  37,)  may  sometimes  be  felt  by  the  hand 
very  distinctly.  It  is  usually  very  strongly  marked  in  the  mu- 
cous and  sonorous  rhonchi,  less  in  the  crepitant,  and  still  less  in 
the  sibilous.     When  the  rhonchus  has  its  seat  remote  from  the 

*  Dry  vesicular  rhonchus. —  Transl.     t  Crackling  rhonchus. — (M.  L.) 


62  THE    CREPITOUS    RHONCHUS. 

point  where  the  instrument  rests,  although  it  is  heard  very 
strongly,  no  vibration  is  felt ;  and  when  this  can  be  discovered 
in  no  point  of  the  surface  of  the  chest,  we  may  conclude  that  the 
cause  of  the  rhonchus, exists  in  the  central  parts  of  the  lungs. 
This  distinction  may  appear  subtle,  but  I  can  assure  the  reader 
that  it  is  one  very  easily  made  ;  and  that  a  very  little  experience 
will  enable  any  one  to  ascertain  the  distance  of  the  rhonchus 
from  the  point  of  exploration. 

Some  of  the  species  of  rhonchus,  especially  the  mucous  and 
crepitous,  cannot  be  distinguished  at  the  distance  of  one  or  two 
inches  from  their  site.  The  other  kinds  may  frequently  be  per- 
ceived through  the  whole  width  of  the  chest,  and  are  thus  often 
combined  with  the  former.  In  this  manner,  while  we  perceive  a 
mucous  rhonchus  on  one  side  of  the  chest,  we  may  at  the  very 
same  instant  hear  a  dry  sonorous  rhonchus,  which  has  its  seat  in 
the  opposite  lung.  This  complication  is,  however,  very  easily 
distinguished  from  a  simple  mucous  rhonchus,  however  noisy. 

From  the  very  striking  and  conspicuous  characters  of  the  va- 
rious rhonchi  described,  it  might  be  imagined  that  they  would 
furnish  some  of  the  most  valuable  of  our  diagnostic  signs.  Taken 
singly,  however,  they  are  very  inferior  in  their  respect  to  the 
data  supplied  by  the  auscultation  of  the  respiration  and  the  voice. 
Conjoined  with  other  signs  they  become  extremely  valuable  :  the 
two  crepitous  rhonchi,  and  also  and  more  especially  the  caver- 
nous, are  frequently  more  certain  than  any  other  of  our  signs.* 

*  In  reference  to  all  the  louder  rhonchi,  it  is  well  to  recollect  that  they  are 
often  audible  through  a  pleuritic  effusion  :  we  must  not  therefore  conclude  from 
their  mere  presence,  that  the  lungs  are  in  contact  with  the  chest. 

In  exploring  the  chest  for  the  rhonchus,  we  use  the  stethoscope  without  the 
plug. —  Trans. 

Since  Laennec,  hardly  any  thing  has  been  added  to  the  excellent  descrip- 
tion given  by  him  of  the  different  rhonchi :  yet  it  has  been  remarked  that  he 
has  not  specified  the  precise  moment,  during  the  act  of  respiration,  at  which 
these  are  jieard.  Sometimes  they  are  heard  only  during  inspiration,  sometimes 
only  during  expiration,  sometimes  equally  in  both  cases.  The  true  crepitous 
rhonchus,  which  takes  place  in  the  air  vesicles,  and  which  consequently  I  call 
by  the  name  of  vesicular  rhonchus,  is  heard  only  at  the  time  of  inspiration. 
There  is,  on  the  other  hand,  another  rhonchus  very  similar  in  sound  but  heard 
both  in  inspiration  and  expiration,  and  more  commonly  in  the  latter  exclusively. 
This  rhonchus  takes  place  in  the  bronchi  of  small  and  middle  calibre.  I  have 
shown  in  my  "  Cliniquc"  that  this  bronchial  rhonchus  with  small  bubbles,  as  I 
denominated  it,  cannot  always  be  distinguished  from  the  true  vesicular  rhon- 
chus :  and  that  consequently,  the  bare  fact  of  the  existence  of  the  one  or  the 
other  of  these  rhonchi,  apart  from  other  symptoms,  will  not  suffice  to  distinguish 
the  diseases  of  the  vesicles  of  the  lungs  from  those  of  the  bronchi.  The^ibi- 
lous  and  sonorous  rhonchi  which  occur  in  infinite  varieties,  and  which  being 
also  seated  in  the  bronchi,  I  call  by  the  generic  appellative  of  dry  bronchial 
rhonchus,  are  heard  perhaps  oftener  in  expiration  than  inspiration.  The  mucous 
rhonchus  may  be  heard  about  as  often  during  one  as  during  the  other  of  these 
respiratory  acts. — Andral. 


METALLIC    TINKLING.  63 


II.  Of  the  metallic  tinkling. 

This  phenomenon  consists  of  a  peculiar  sound  which  bears  a 
striking  resemblance  to  that  emitted  by  a  cup  of  metal,  glass,  or 
porcelain,  when  gently  struck  with  a  pin,  or  into  which  a  grain 
of  sand  is  dropped.  This  sound  does  not  at  all  depend  on  the 
nature  of  the  materials  of  which  the  stethoscope  is  composed  : 
it  is  perceived  during  respiration,  speaking  and  coughing ;  but 
is  much  more  perceptible  during  the  two  latter  than  the  former. 
The  reverse  of  this  is,  however,  sometimes  the  case.  It  is,  in 
general,  heard  in  the  most  striking  manner,  during  cougjiing  ;  and 
when  in  any  degree  doubtful,  this  action  ought  to  be  performed. 

The  metallic  tinkling  produced  by  the  voice,  differs  according 
as  pectoriloquy  exists  or  not.  In  the  former  case,  the  tinkling, 
as  well  as  the  voice,  traverses  the  tube :  in  the  latter,  we  merely 
hear  within  the  chest  a  slight  sharp  sound  like  that  occasioned 
by  the  vibration  of  a  metallic  cord  touched  by  the  finger. 

The  metallic  tinkling  always  originates  in  a  morbid  excavation 
within  the  chest,  containing  partly  air  and  partly  liquid.  It  ex- 
ists only  therefore  in  two  cases — viz.  where  a  serous  or  purulent 
effusion  co-exists  with  pneumo-thorax  ;  or  when  a  large  tuber- 
culous excavation  of  the  lung  is  only  partly  filled  with  very 
liquid  pus.  It  is  further  necessary  for  the  manifestation  of  this 
phenomenon,  in  cases  of  empyema  or  hydro-thorax  complicated 
with  pneumo-thorax,  that  the  cavity  of  the  pleura  should  com- 
municate directly  with  a  bronchial  tube  by  means  of  a  fistula, 
such  as  has  place  when  a  tuberculous  vomica,  abscess  or  eschar 
of  the  lungs,  opens  into  the  chest.  The  sign  may,  on  this  ac- 
count, be  considered  as  pathognomonic  of  this  triple  lesion.* 
From  it  we  may  also  further  have  an  idea  of  the  size  of  the  fis- 
tulous perforation,  as  well  as  of  the  relative  proportion  of  air 
and  liquid  in  the  chest ;  since  the  phenomenon  is  more  distinct 
according  as  the  fistula  is  larger  ;  while  the  extent  of  the  vibra- 
tions of  the  sound  corresponds  wih  the  extent  of  the  spaces 
occupied  by  the  air.f 

Sometimes  the  tinkling  assumes  another  character,  and  strik- 
ingly resembles  the  sound  produced  by  blowing  into  a  #ask  or 

*  Dr.  Williams  has  shown  (Rat.  Expos,  p.  136,  et  seq.)  that  communication 
with  the  hronchi  is  not  essential  to  the  production  of  this  phenomenon ;  and 
certainly,  in  one  of  the  most  distinct  examples  of  the  phenomenon  that  I  ever 
nut  with,  no  communication  could  be  discovered,  on  dissection,  between  the 
bronchi  and  the  fluids  on  the  sac  of  the  pleura.—  Transl. 

t  This  may  also  be  very  exactly  done  by  means  of  auscultation  and  percussion  : 
the  latter  gives  the  sound  of  great  emptiness,  intermixed  now  and  then  with  tink- 
ling. I  conceive  that  the  phenomenon  will  be  less  distinct  when  the  liquid  is  in 
n  nj  small  quantity,  than  where  it  is  in  more  equal  proportion  with  the  air. — Au- 
thor. 


64  METALLIC    TINKLING. 

bottle.  This,  like  the  tinkling,  is  equally  produced  by  the 
cough,  voice,  or  respiration ;  and  in  some  cases  the  tinkling 
accompanies  one  of  these,  and  the  buzzing  the  other.  I  have 
named  it  from  analogy,  utricular  buzzing,  or  amphoric  reson- 
ance (bourdonnement  amphorique.)  This  sound  sometimes  co- 
exists and  sometimes  alternates  with  metallic  tinkling.  Where 
the  resonance  or  buzzing  exists  alone,  or  much  more  frequently 
than  the  tinkling,  I  have  been  led  to  attribute  it  either  to  there 
being  more  than  one  fistulous  opening,  or  to  the  cavity  in 'which 
it  originates  being  very  large,  and  containing  only  a  very  small 
quantity  of  liquid.* 

I  had  long  suspected  that  the  metallic  tinkling  and  amphoric 
resonance  would  be  heard  after  the  operation  of  empyema,  but 
it  was  not  till  April,  1822,  that  I  was  enabled  to  verify  my  con- 
jecture, in  the  case  of  a  patient  who  had  been  operated  on  about 
a  month  before.  When  an  injection  was  thrown  in  by  the 
wound,  the  fall  of  the  liquid  upon  that  previously  in  the  cavity  of 
the  chest,  produced  a  well-marked  tinkling.  The  stethoscope 
did  not  detect  any  respiratory  sound  in  the  part  affected,  but  the 
entrance  and  escape  of  the  air  through  the  wound  gave  rise  to 
an  extremely  distinct  utricular  buzzing.  Upon  plugging  the 
wound,  a  slight  and  dull  hissing,  occasioned  by  the  passage  of  the 
air  by  the  side  of  the  tent,  was  only  heard ;  but  when  the  patient 
spoke,  a  distinct  tinkling  was  perceived.  This  last  fact  would 
seem  to  show  that  a  large  communication  with  the  external  air 
converts  the  tinkling  into  simple  buzzing.  It  is  worthy  of  note 
in  this  case,  that  there  was  no  fistulous  communication  between 
the  pleura  and  bronchi,  and  consequently  that  the  tinkling  sound 
could  only  be  produced  by  the  vibration  occasioned  by  the  re- 
sonance of  the  voice  in  the  lung,  which  latter,  it  is  further  to  be 
observed,  was  greatly  compressed  and  covered  with  a  strong  false 
membrane.  The  metallic  tinkling  and  utricular  buzzing  never 
exist  unless  where  the  air  in  the  pleura  communicates  with  the 
bronchi,  except  in  the  rare  case  mentioned  in  the  first  note  in  this 
page.f 

I  expect  that  future  observation  will  discover  other  phenomena 
foreign  to  those  naturally  produced  by  the  respiration,  cough, 

*  The  metallic  tinkling  isflso  sometimes  heard  independently  of  the  voice, 
cough,  or  respiration  ;  namely,  when  a  patient  affected  with  pneumo-thorax 
with  liquid  effusion,  is  placed  in  the  sitting  posture,  and  some  of  the  fluid 
which  still  adheres  to  the  upper  part  of  the  cavity,  falls  in  drops  into  that  be- 
neath.— Author.  , 

t  There  is  a  phenomenon  of  no  value  as  a  sign,  but  which  an  inexperienced 
observer  might  perhaps  mistake  for  the  metallic  tinkling.  If  one  percusses  the 
chest  at  the  same  time  that  the  stethoscope  is  applied,  more  especially  close  to 
the  instrument,  wc  perceive  a  sort  of  metallic  clicking,  very  like  that  produced 
by  the  handling  of  fire-arms  in  the  military  exercise.  The  same  is  sometimes 
perceived,  in  a  less  degree,  during  coughing. — Author. 


METALLIC    TINKLING.  65 

and  action  of  the  heart,  and  which  may  prove  useful  signs  in 
particular  cases ;  yet  I  think  it  probable  that  such  signs  will  be 
few  in  number ;  since,  in  the  period  that  has  elapsed  since  the 
publication  of  my  first  edition,  my  own  researches  as  well  as 
those  made  in  all  the  hospitals  of  Paris  by  a  great  many  phy- 
sicians and  pupils,  have  discovered  only  a  single  one  of  the  kind. 
I  owe  this  to  Dr.  Honore,  who  first  perceived  it  in  a  case  of 
pleuro-peripneumony  in  the  spring  of  1824,  and  afterwards  in 
June  the  same  year.  This  latter  patient  I  saw,  and  made  the 
following  observations  on  his  case :  the  sound  of  respiration  was 
feeble  over  the  whole  chest,  and  nearly  extinct  in  the  inferior 
part  of  the  left  side,  which  had  been  the  seat  of  the  effusion. 
On  applying  the  stethoscope  on  the  fourth  rib,  about  three  inches 
from  its  cartilaginous  portion,  I  perceived  a  dull  sound,  such  as 
would  be  produced  under  the  stethoscope  by  the  friction  of  the 
finger  against  a  bone,  and  further  conveying  the  sensation  as  of 
a  body  rising  and  falling,  and  at  the  same  time  rubbing  some- 
what harshly  against  another.  The  site  of  the  phenomenon  was 
evidently  very  close  to  the  walls  of  the  chest.  It  was  only  very 
distinct  when  the  inspirations  were  deep ;  and  at  these  times  not 
only"  was  the  patient  sensible  of  the  circumstance,  but  it  was  per- 
ceptible to  us  on  applying  the  hand  over  the  part.  I  have  since 
observed  the  same  thing  in  twelve  or  fifteen  cases,  under  different 
circumstances,  and  have  been  able  to  ascertain  its  most  frequent 
cause.  In  most  cases,  then,  this  phenomenon,  (which  I  shall  call 
the  sound  of  friction  of  ascent  and  descent)  is  occasioned  by 
the  interlobular  emphysema  of  the  lungs.*  Together  with  the 
crackling  rhonchus,  or  dry  crepitous  rhonchus  with  large  bub- 
bles, it  is  indeed  the  pathognomonic  sign  of  this  lesion ;  and,  as 
will  be  seen  hereafter,  may  offer  many  varieties  of  character. 

In  passing  in  review  all  the  known  lesions  of  the  lungs  and 
pleura,  there  is  one  other  which  might  possibly  give  occasion  to 
this  sound  of  friction, — the  existence,  namely,  of  a  cartilaginous, 
bony,  tuberculous,  or  other  indurated  tumor  projecting  from  the 
surface  of  the  lung.  This  is,  however,  a  mere  conjecture ;  but 
should  it  prove  true,  it  is  probable  that  the  case  in  question 
would  be  readily  distinguishable  from  emphysema, — firstly,  be- 
cause it  would  present  none  of  the  other  signs  of  the  last-men- 
ed  disease  ;  and  secondly,  because,  owing  to  the  accompanying 
humidity  of  the  surfaces,  the  resulting  sounds  would  be  duller 
and  softer.* 

As  the  exploration  of  the  heart  and   large  vessels  affords  only 

*  Subsequent  observations  have  enabled  M.  Reynaud  to  establish  the  fact 
which  Laennec  only  conjectured.  The  sound  of  friction  is  perceived  in  every 
case  where  the  pleura  is  rough  or  uneven.  It  exists  in  pleurisy  with  little  or  no 
liquid  effusion,  and  where  the  pleura  is  merely  covered  with  a  false  membrane  ; 
and  likewise  in  cases  where  the  fluid  is  only  in  moderate  quantity,  and  the  free 

9 


66  METALLIC    TINKLING. 

diagnostic. signs  in  the  diseases  of  these  organs,  I  shall  defer  the 
notice  of  this  branch  of  auscultation  until  I  come  to  treat  of  them, 
and  I  shall  transfer  to  the  Appendix  the  application  of  the 
method  to  the  diagnosis  of  several  cases  unconnected  with  diseases 
of  the  chest. 

motion  of  the  lung  is  not  impeded  by  ancient  adhesions.  In  this  last  £ase> 
when  the  lung,  in  certain  positions  oi' the  body,  rises  above  the  level  of  the 
effusion,  and  rubs  against  the  thoracic  parietes,  the  sound  of  friction  is  heard  im- 
mediately over  this  point.  When  the  effusion  becomes  considerable,  it  disappears, 
and  again  returns  when  ihe  fluid  is  lessened.  In  most  cases  the  sound  is  per- 
ceptible by  the  application  of  the  hand,  as  well  as  by  auscultation  :  it  may  even 
be  heard  at  some  distance  from  the  patient;  and  sometimes  it  is  very  percepti- 
ble to  the  latter.  The  sound  of  friction  is  not,  it  will  now  be  perceived,  exclu- 
sively confined  to  the  case  of  pulmonary  emphysema  :  it  is  met  with  in  pleu- 
risy, and  may  be  regarded  as  a  good  sign,  since  it  indicates  that  the  effusion  is 
not  so  great  as  to  prevent  the  lung  from  being  dilated,  so  as  to  reach  the  walls  of 
the  chest.  Neithec  does  it  appear,  as  Laennec  imagined,  to  be  different  in  the 
two  cases.  I  am  even  disposed  to  believe,  that  when  it  exists  in  emphysema,  this 
affection  is  complicated  with  pleurisy.  In  confirmation  of  this,  I  may  state,  that 
in  the  notes  of  Laennec's  own  cases  taken  by  myself,  I  find,  almost  always,  this 
complication  expressly  named,  where  the  sound  of  friction  is  recorded.  The 
same  observation  applies  to  M.  Reynaud's  third  case  (Journ.  Hebd.  No.  65;)  and 
even  Andral  bears  testimony  to  the  accuracy  of  M.  Reynaud's  views.  (Clin.  Med. 
t.  ii.  p.  613,  2nd  Ed.) 

The  foregoing  pathological  facts  led  M.  Reynaud  to  examine  whether  there 
might  not  exist  an  habitual  friction  between  the  pulmonary  and  costal  pleura  in 
the  state  of  health.  And  this  seemed  established  by  a  priori  considerations, — 
namely,  by  the  invariable  formation  of  an  accidental  serous  tissue,  wherever  a 
false  joint  or  accidental  movement  is  established,  and  by  the  obliteration  of  the 
articular  serous  cavities  on  the  abolition  of  all  motion  of  the  parts.  With  the 
view  of  proving  the  fact,  M.  Reynaud  made  an  experiment  on  a  living  animal, 
and  believed  that  he  could  distinctly  perceive  the  motion  of  the  lungs  against 
the  ribs  during  inspiration  and  expiration.  In  the  state  of  health,  the  sound  pro- 
duced by  this  friction  of  the  parts  is  not  perceptible  owing  to  the  slippery  smooth- 
ness of  the  two  membranes,  or  is  confounded  with  that  of  the  respiration  ;  but 
when  the  natural  condition  of  the  parts  is  altered  by  inflammation  or  any  other 
cause,  it  then  becomes  manifest.  (See  Journ.  Hebdom.  de  Med.  No.  65.) — M.L.* 
*  I  have  frequently  observed  in  living  animals,  particularly  horses,  that  at 
the  moment  of  inspiration,  when  the  ribs  rise,  the  lungs  subside,  and  that  there 
is  actually  a  friction  between  the  two  surfaces  of  the  pleurae — which  does  not 
take  place  when  the  pleural  surfaces  are  smooth  and  free  from  disease.  When 
the  surfaces  of  the  membrane  have  lost  their  polish  and  have  become  rough  or 
uneven,  the  sound  of  friction  becomes  audible.  This  is  the  sound  which  is 
heard  in  the  the  pericardiiim,  as  we  shall  see  presently,  when  the  smoothness 
of  the  inner  surface  of  this  envelope  is  destroyed  by  inflammation  :  only  there 
is  a  difference  of  rapidity  in  the  two  sounds. 

The  sound  of  friction  arising  from  the  action  of  the  two  surfaces  of  the  pleu- 
rae against  each  other,  is  often  so  loud  that  it  may  be  heard  at  the  distance  of 
several  feet,  and  often  by  the  patient  himself.  The  sound  is  of  short  duration, 
though  in  some  cases  it  continues  for  months.  I  have  known  it  last  for  three 
months,  in  a  young  man  who  made  it  known  to  me  as  he  began  to  recover  from 
a  pleurisy  of  the  left  side.  This  sound  continued  long  after  he  had  completely 
recovered  :  finally  it  disappeared. 

I  have  recently  discovered  a  sound  of  the  same  kind  in  the  femoro-tibial 
articulation  of  a  man  with  symptoms  of  incipient  inflammation  at  this  point. 
The  sound  was  produced  by  moving  the  patella  in  a  certain  manner ;  and  when 
first  heard,  might  have  been  mistaken  for  the  crepitus  produced  by  the  action  of 
a  fractured  bone.  The  deception  was  so  complete,  that  in  the  first  moments  of 
the  examination,  I  had  no  doubt  the  patella  was  fractured.  M.  Mariolin  stated 
to  me  that  he  knew  a  case  precisely  similar.  This  could  not  have  been  accoun- 
ted for  before  the  recent  discoveries  respecting  the  sounds  produced  by  inflamma- 
tion oi  the  serous  membranes  of  the  thorax.— Jindral. 


PART  SECOND. 


DISEASES   OF  THE   BRONCHI,   LUNGS,    AND 
PLEURA. 

I  shall  not  here  attempt  with  the  Nomologists,  to  divide  the 
diseases  of  which  I  propose  to  treat,  into  genera  and  species. 
Such  an  arrangement  appears  to  me  incompatible  with  the  nature 
of  medical  science.  The  zoological  and  botanical  species  are  dis- 
tinct beings,  while  diseases  are  merely  modifications  in  the  tex- 
ture of  the  animal  organs,  in  the  composition  of  their  fluids,  or 
in  the  order  of  their  functions.  I  shall  still  less  endeavor  to 
ascertain  the  primary,  or  as  they  are  called  proximate  causes 
of  diseases.  The  vanity  of  researches  of  this  kind  is  sufficiently 
proved  by  the  profound  oblivion  into  which  all  theories  of  this 
nature  have  successively  fallen.  I  shall  content  myself  with  de- 
scribing the  diseases  of  the  thoracic  organs, — that  is  to  say,  such 
pathological  phenomena  as  are  well  marked  and  easily  distin- 
guishable from  others.  I  will  state  the  characters  by  which  they 
may  be  recognized  during  life  and  in  the  dead  body :  and  the 
treatment  which  experience  has  proved  to  be  most  efficacious. 

When  the  disturbance  of  the  functions,  which  is  in  fact,  pro- 
perly speaking,  the  disease,  is  clearly  dependent  on  the  change 
of  structure,  or  is  so  connected  with  this  as  to  bear  a  direct 
relation  to  it  as  to  intensity.  I  shall  commence  the  description  of 
the  disease  with  this  organic  alteration  ;  because  it  constitutes 
the  part  of  the  disease  which  is  most  positive  and  least  subject  to 
variation.* 

*  This  method  which  I  have  been  one  of  the  first  to  recommend,  appears  to 
me  far  preferable  to  the  one  generally  pursued  to  the  present  time,  which  has 
been  to  commence  with  an  exhibition  of  the  symptoms  of  a  disease,  and  finish 
the  description  by  a  history  of  the  organic  derangements  which  cause  or  accom- 

Eany  it,  as  if  it  were  possible  to  understand  the  symptoms  without  a  previous 
itowlcdge  of  these  organic  alterations.  A  description  of  these  ought  certainly 
to  precede  the  account  of  the  symptoms  which  depend  upon  them.  How  is  it 
possible,  for  instance,  to  explain  properly  the  stethoscopic  signs  of  pneumonia 
or  pleurisy,  without  knowing  beforehand,  the  various  alterations  which  the 
\n:.?  nnd  the  pleura  undergo  in  these  diseases?  Is  not  the  case  exactly  the 
same  with  diseases  of  the  heart '     Is  there,  in  a  word,  a  single  malady  in  which 


68  DISEASES    OF    THE    BRONCHI,    &C. 

In  this  way,  I  shall  successively  notice  all  the  organic  lesions 
to  which  the  several  textures  of  the  lungs  are  subject.  After- 
wards I  shall  examine  the  disorders  of  this  organ,  which  may 
exist  without  any  discoverable  change  of  structure,  and  which 
must,  therefore,  be  considered  rather  as  alterations  in  the  fluids, 
or  in  that  which  gives  motion  (to  use  the  language  of  Hippocrates 
r&  Spiiovra,^  m  other  words,  nervous  diseases.* 

the  symptoms  are  not  more  clear  and  rational  to  an  observer  acquainted  with 
the  anatomical  lesions  that  attend  it  ?  Let  it  not  be  said,  then,  that  by  such  a 
procedure,  the  history  of  a  disease  is  begun  at  the  end.  There  would  be  some 
ground  for  the  objection,  were  the  matter  under  consideration  a  mere  clinical 
case;  but  it  is  otherwise  with  the  general  description  of  a  disease. — Andral. 

*  I  am  not  of  the  number  of  those  who  maintain  that  the  functions  of  an 
organ  cannot  be  disturbed  unless  it  has  undergone  a  change  in  structure.  This 
disturbance  may  arise  from  a  totally  different  cause.  The  gravel,  for  instance, 
with  an  excess  of  azote  in  the  blood,  does  not  arise  from  an  alteration  in  the 
texture  of  the  kidneys.  But  from  the  fact  that  functional  disorders  cannot 
always  be  explained  by  adequate  organic  changes,  we  must  not  too  hastily  con- 
clude that  these  changes  do  not  exist,  and  infer  off"  hand,  as  Laennec  does  in 
this  place,  that  the  symptoms  arise  from  alterations  in  the  fluids  or  nervous 
system. 

The  progress  of  pathological  anatomy  may  discover  in  an  organ  whose  func- 
tions are  decayed,  a  lesion  which  has  lurked  unseen.  Has  not  Laennec  himself 
found  in  pulmonary  emphysema  the  cause  of  certain  asthmas  which  up  to  the 
period  of  his  discoveries,  were  regarded  as  nervous  diseases  ? — Andral. 


BOOK  FIRST. 

DISEASES  OF  THE  BRONCHI. 


CHAPTER  1. 


OF  THE  CATARRHAL  AND  INFLAMMATORY  AFFECTIONS  OF  THE 
MUCOUS  MEMBRANE  OF  THE  BRONCHI. 

The  inflammatory  affections  of  the  mucous  membrane  of  the 
bronchi,  may  be  divided  into  the  catarrhal,  the  plastic  or  crusty, 
and  the  ulcerous. 

The  pulmonary  catarrhs  present  a  great  many  varieties  in  re- 
spect to  the  nature  and  quantity  of  the  expectoration,  of  the  acute 
or  chronic  state  of  the  disease,  or  of  the  accompanying  circum- 
stances. I  shall  describe  them  in  the  following  order: — 1.  the 
acute  mucous  catarrh ;  2.  the  chronic  mucous  catarrh ;  3.  the 
pituitous  catarrh ;  4.  the  dry  catarrh ;  and  shall  conclude  by 
noticing  some  other  varieties  produced  by  the  difference  of  the 
occasional  causes  and  other  accessary  circumstances. 

I  prefer  the  term  catarrh  to  that  of  bronchitis,*  employed  by 

*  In  applying  the  name  of  catarrh  to  the  greater  part  of  the  diseases  of  the 
mucous  membrane  of  the  bronchi,  which  were  attended  with  more  or  less 
secretion,  the  ancients  were  led  to  bestow  too  little  regard  to  the  influence  of 
inflammation  in  the  development  of  these  disorders.  They  acknowledged, 
nevertheless,  an  inflammatory  catarrh,  but  in  cases  only  where  the  inflammation 
of  the  bronchi  was  accompanied  by  fever,  strong  arterial  excitement,  and  a 
general  reaction  more  or  less  strong.  In  such  cases  venesection  was  employed. 
When  these  symptoms  did  not  appear,  they  supposed  another  sort  of  disease, 
and  applied  a  different  course  of  treatment. 

The  moderns  in  their  turn,  by  substituting  the  term  bronchitis  for  catarrh, 
have  singled  out  for  notice  the  effect  of  inflammation  in  producing  the  disorder. 
Running,  however,  into  the  opposite  extreme,  they  overlook  in  all  disorders  of 
the  air-passages,  everything  besides  inflammation.  All  these  diseases  they  call 
by  the  name  of  bronchitis,  which  is  as  revolting  to  science  as  if  all  functional 
derangements  of  the  stomach  were  comprehended  in  the  general  term  of  gastritis. 
I  have  endeavored  to  show  in  another  work  (Precis  d' Anatomic  pathologique) , 
that  inflammation  is  a  complex  phenomenon,  comprising  many  other  phenomena, 
each  of  which  may  have  a  separate  existence,  and  one  independent  of  what 
we  call  inflammation.     I  have  thus  been  able  to  show  the  existence  in  all  organs 


70  ACUTE    MITOT'S    CATARRA. 


some  modern  authors,  because  catarrh  forms  the  link  which 
unites  the  inflammations  to  the  congestions,  and  to  the  fluxes 
purely  passive,  and  because  in  certain  cases  of  chronic  catarrh, 
it  is  at  least,  very  doubtful  whether  the  disease  be  really  an  in- 
flammation or  not. 

Sect.  I.   Of  the  acute  mucous  catarrh. 

Pulmonary  catarrh  is  unquestionably  one  of  the  most  frequent 
of  diseases,  insomuch  that  most  persons  are  affected  with  it,  in 
some  degree  or  other,  almost  every  year.  .  Notwithstanding  this 
frequency,  it  is  perhaps  less  understood  than  many  rarer  diseases. 
In  most  cases,  it  occurs  in  so*  slight  a  degree  as  scarcely  to  de- 
range, in  any  respect,  the  functions  of  the  body,  or  to  prevent 
the  individual  from  following  his  usual  occupations  ;  occasionally, 
however,  it  is  of  sufficient  violence  to  endanger  life. 

Doubts  may  still  be  raised  respecting  the  nature  of  this  disease. 
If  in  some  cases  it  approaches  the  nature  of  croup,  a  complaint 
eminently  inflammatory,  in  most  other  instances  it  exhibits  the 
character  of  a  simple  congestion  merely,  and  in  some,  those  only 
of  an  atonic  or  passive  congestion.  Its  causes  are  not  better  un- 
derstood, for,  to  notice  only  the  one  most  commonly  adduced, 
it  seems  certain  that  the  change  from  heat  to  cold  does  not  pro- 
duce it  more  effectually,  than  the  change  from  cold  to  heat.  The 
effects  of  catarrh  are  equally  a  matter  of  dispute  ; — many  still 
considering  it,  with  the  ancients,  as  the  cause  of  phthisis,  while 
the  result  of  modern  pathological  researches  appears,  to  others, 
entirely  to  invalidate  this  opinion. 

Anatomical  characters.  A  redness  more  or  less  marked,  and 
at  most  a  slight  thickening  of  the  internal  membrane  of  the 
bronchi,  are  the  only  traces  which  this  disease  leaves  in  the 
affected  organs ;  if  we  except  a  certain  quantity  of  phlegm  in 
the  bronchi,  resembling  that  expectorated  by  the  patient.  The 
redness  and  swelling  very  rarely  occupy  the  whole  bronchial 
membrane,  even  of  one  lung.  When  the  contrary  is  the  case, 
the  disease  is  very  severe,  and  accompanied  by  a  violent  fever. 
Most  commonly  there  is  congestion  only  in  certain  parts  of  the 
membrane  in  one  or  both  lungs,  even  when  there  is  much  fever 

of  a  morbid  state  which  consists  essentially  in  a  lesion  of  secretion  or  nutrition 
the  development  of  which  it  is  mere  hypothesis  to  explain  by  a  state  of  inflam- 
mation, or  simple  irritation.  I  allow,  nevertheless,  that  the  "latter  may  in  some 
cases  precede  these  lesions,  yet  it  is  at  most  only  an  occasional  cause,  and  all 
the  lesions  may  occur  with  it.  I  admit,  for  instance,  that  an  abundant  secretion 
may  take  place  in  the  inner  surface  of  the  bronchi,  without  any  preceding  in- 
flammation :  this  is  bronchorraa.  There  are,  therefore,  bronchial  fluxe"  as 
well  as  intestinal  and  cutaneous  fluxes.  These  different  morbid  conditions  call 
for  a  treatment  altogether  different  from  that  which  would  be  proper  were  thev 
the  result  of  inflammation. — Aniral. 


ACUTE    MUCOUS    CATARRH.  71 

and  expectoration.  The  portions  which  are  red  and  swollen, 
are  usually  more  consistent  than  natural ;  sometimes  they  are 
somewhat  softer,  particularly  in  the  catarrhs  which  accompany 
severe  fevers ;  and  occasionally,  the  degree  of  the  softening  is 
equal  to  that  which  occurs  in  the  mucous  membrane  of  the  sto- 
mach and  intestines,  in  certain  cases,  and  which  led  Hunter  to 
fancy  that  this  membrane  is  sometimes  dissolved  or  digested, 
after  death.*  The  extent  and  intensity  of  the  redness  are  not 
always  proportioned  to  the  violence  of  the  inflammation,  the 
quantity  of  the  expectoration,  or  the  acuteness  of  the  case. 
Thus,  in  the  catarrh,  whether  latent  or  not,  which  complicates 
fevers,  we  find  the  membrane  swollen  and  of  a  livid  red  over 
almost  its  whole  extent,  and  also  softened  here  and  there  ;  while 
in  the  idiopathic  disease,  even  when  very  acute,  it  exhibits  marks 
of  inflammation  in  certain  points  only.f 

*  Late  researches  have  shown  that  the  old  opinion  as  to  the  power  of  the 
gastric  juice   in  softening   and   destroying  the  coats  of  the  stomach,  is  not  with- 
out foundation.  This  may  be  exemplified  by  killing  rabbits  while  the  process  of 
digestion  is   going  on  within   them:   here  we  shall   find   the  stomach  dissolving 
and   actually   destroyed   in   those   points  actually  in  contact  with   the   aliment, 
which   has    begun   to   turn   to  chime.     The   progress   of  the   solution    may  be 
marked  by  the  eye — it  operates  from  within  outwards,  beginning  with  the  mu- 
cous membrane  and  ending  with  the  peritoneal  coat.     I  have  repeated  the  ex- 
periments  began   by  Dr.  Carswell,  and  can  vouch  for  the  accuracy  of  his  state- 
ments.    These  experiments  have  not  been  tried  with  the  proper  (are  upon  any 
animals  except   rabbits.     Some   cases  have  been  cited  of  the  human  body,  (see 
my  Pricis  d'Anatomit  pathologique,)  where  it  seems  the  stomach  has  been  per- 
forated  after   death,   doubtless   under   the   influence   of  causes   similar  to  those 
which    produced   the   same   effect  in   the   animals  described   by   Dr.  Carswell. 
Since  the   publication  of  these   experiments,  I  have   had   three  opportunities  of 
examining  the   stomach   of  individuals  who   died   suddenly  with   the   digestive 
powers  in  full  activity  and  without  any  marks  of  ill   health.     One  of  these  in- 
dividuals had  been  guillotined  ;  the  second  a  laborer,  was  killed  by  a  fall  ;  and 
the  third  died  in  a  few  moments  from  a  rupture  of  an  aneurism  of  the  abdomi- 
nal aorta.      In   each  of  these,  the   stomach    contained  a  remarkable   quantity  of 
chymous  matter :  yet  the  elaboration  of  the  aliment  was   not  accomplished  in 
either  of  them,  and  some  portions  of  it  were   in  the  natural  state.     In  the  guil- 
lotined subject,  the  mucous  membrane  of  the  stomach,  particularly  towards  the 
great  cul-de-sac.  was  reduced  to  a  soft,  whitish  pulp,  which  was  scraped  away,  like 
liquid    mat. er.  by  a  slight   action   of  the   back   of  the   scalpel:   in    some    places 
there  were  even  no  marks  of  its  existence.     The  sub-mucous  cellular  tissue  was 
bare  ;   the  other   coats   had   undergone   no   change.     In  the  body  of  the  laborer 
killed  by  the  fall,  I  observed  precisely  the  same  condition  of  the  mucous  mem- 
brane, while  the  coats   beneath  it   had   lost   much  of  their  consistence,  and   the 
stomach  might  be  torn  in  some   parts   by  a  very  slight  force.     In  the  the  third 
subject,  on   the  contrary,  I  found  nothing  similar  to  this.     The  mucous  mem- 
brane had  a  good  consistence   throughout,  and   the  same  was  true  in  respect  to 
the  coats  beneath  it.     Thus,  while  we  admit  that  the  human  stomach  may.  like 
the  stomach  of  rabbits,  be  softened  and  eaten  through  in  cases  of  death  during 
digestion,  we  must  add   that  this  does  not  happen  in  all  cases.     This  variation 
depends,  doubtless,  on  the  existence  of  certain  peculiarities  not  yet  ascertained. 
— And  ml . 

t  It  deserves  notice,  in  this  place,  that  the  redness  and  softening  of  the  bron- 
chial  membrane  are  always  the  more  marked  according  as  the  examination  is 
remote  from  the  period  of  death,  and  the  decomposition  of  the  body  more  ad- 
\anccd. — Author. 


72  ACUTE    MUCOUS    CATARRH. 

The  pulmonary  catarrh  is  accompanied,  from  its  very  com- 
mencement, with  a  marked  alteration  of  the  bronchial  secretion. 
At  first  this  is  scantier  than  natural,  or  is  almost  totally  sup- 
pressed :  in  the  latter  case  it  possesses  the  characters  which  we 
will  hereafter  notice  when  treating  of  the  dry  catarrh.  In  a 
short  time,  it  becomes  thin,  transparent,  and  acrid,  or  salt  to  the 
taste.  Towards  the  end  of  this  second  period,  especially  if  this 
has  lasted  some  days,  the  expectoration  becomes  thicker  and 
slightly  viscid,  without  at  all  losing  its  transparency  ;  and  in 
certain  cases  entirely  resembles  raw  white  of  egg.  It  then  gra- 
dually becomes  opaque,  and  assumes  a  whitish,  yellowish,  or 
slightly  greenish  color,  and  is  more  consistent,  but  is  still  viscid. 
In  this  state  it  obstructs,  in  a  greater  or  less  degree,  the  bronchial 
tubes,  particularly  those  of  a  small  or  middle  size,  so  as  to  im- 
pede the  free  transmission  of  the  breath,  and  to  give  rise  to  the 
mucous  rhonchus.  In  this  case,  the  respiration  is  suspended  in 
the  portion  of  the  lungs  supplied  by  the  obstructed  bronchi,  until 
the  phlegm  is  discharged.  The  quantity  and  consistence  of  the 
secreted  mucous  vary  extremely.  In  some  cases  it  is  almost  as 
solid  as  a  polypous  concretion.  M.  Andral  relates  two  cases  where 
the  principal  branch  distributed  to  the  upper  lobe  was  obstructed 
by  concrete  mucus  of  this  kind ;  and  in  one  of  these  it  extended 
into  three  or  four  of  the  divisions  of  this  branch.* 

There  exists  no  sign  capable  of  distinguishing  this  from  other 
obstructions  of  the  bronchi.  In  the  two  cases  of  Andral,  there 
was  sudden  dyspnoea,  and  death  within  twenty-four  hours ;  but  it 
appears  to  me  doubtful,  after  what  has  been  stated  and  what  we 
shall  notice  hereafter,  of  the  slight  degree  of  inconvenience 
arising  from  the  suspension  of  respiration,  in  even  a  large  extent 
of  lung,  that  the  death  of  these  patients  was  owing  to  the  cause 
mentioned.!     I  am  the  more  confirmed  in  this  opinion  from  having 

*  Clinique  Medicale,  Vol.  II.  Obs.  xi.  andxii. 

t  The  structure  of  the  bronchi  explains  the  difficulty  of  breathing  caused  by 
the  obliteration  of  one  of  these  conduits.  The  bronchi,  in  fact,  are  not  like  the 
blood  vessels,  which  communicate  constantly  with  each  other,  and  by  their 
innumerable  anastomoses,  restore  the  circulation  impeded  at  any  point :  the 
bronchi,  on  the  contrary,  are  more  isolated.  The  principal  one  which  admits 
the  air  into  each  lobe  of  the  lung  has  no  communication  with  those  which  ad- 
mit it  to  the  other  lobes  :  each  lobule  receives  the  air  in  its  turn  from  a  bronchial 
tube  exclusively  its  own,  and  which  cannot  distribute  air  to  any  other  part.  If 
then  the  large  bronchial  tube,  which  carries  this  supply  to  one  of  the  pulmona- 
ry lobes,  becomes  obliterated,  the  whole  lobe  becomes  useless  for  respiration, 
and  the  dyspnoea  thus  occasioned,  will  become  as  great  as  if  this  lobe  had  grown 
impermeable  to  the  air  in  consequence  of  an  hepatized  state  of  it.  In  persons 
attacked  with  chronic  catarrh  here  referred  to  by  Laennec,  there  is  in  reality  at 
intervals,  a  suspension  more  or  less  obvious,  of  breathing,  in  consequence  of 
an  engorgement  of  the  mucous  membrane  of  a  certain  number  of  bronchi :  but 
this  engorgement  can  never  become  so  great  as  to  cause  an  obliteration  of  the 
air  tubes,  except  in  their  small  divisions;  the  respiration  then,  suffers  a  sus- 
pension in  some  of  the  lobules,  and  there  is  no  similarity  between  these  case3 
and  mine. — Andral. 


ACUTE  MUCOUS  CATARRH.  73 

seen  cases  apparently  similar,  of  which  the  subjects  could  hardly 
be  considered  as  indisposed.  The  following  is  a  case  of  this 
kind :  A  man  forty  years  of  age,  and  subject  to  a  dry  catarrh 
(which  was  almost  always  latent)  for  the  last  twenty  years 
and  which  had  only  given  occasion  during  all  this  time  to 
two  or  three  fits  of  asthma,  was  seized,  in  the  winter  of  1821, 
with  a  slight  acute  catarrh,  which  did  not  prevent  him  from 
following  his  usual  occupation.  This  catarrh  was  at  first  dry, 
and  attended  with  little  cough  or  dyspnoea.  After  eight 
days  he  began  to  cough  rather  violently  every  morning,  with 
the  feeling  as  if  something  was  lodged  about  the  root  of  the 
right  lung ;  corresponding  to  which  point,  about  the  inner  edge 
of  the  scapula,  he  experienced  a  sense  of  great  heat.  The  fit 
of  coughing  returned,  but  with  less  violence,  every  evening. 
Things  went  on  in  this  way  for  four  or  five  days,  when,  during 
a  violent  fit  of  coughing,  accompanied  with  nausea  and  a  great 
flow  of  tears,  he  expectorated  an  immense  clot  of  mucus,  capable 
of  filling  a  spoon,  and  weighing  more  than  half  an  ounce.  It 
was  yellow,  opaque,  viscid,  unmixed  with  air,  and  of  a  middle 
consistence  between  that  of  the  usual  mucous  sputa  and  of  false 
membrane.  Immediately  after  its  discharge,  the  sense  of  warmth 
existing  in  the  point  mentioned,  changed  to  a  painful  heat,  which 
lasted  nearly  all  day,  but  which  did  not  hinder  the  man  from 
going  abroad.  For  several  days  after  this  he  expectorated 
every  morning,  but  with  ease,  some  mucous  sputa  of  a  moderate 
size  and  the  usual  consistence ;  and  these  entirely  ceased  within 
the  week.# 

In  the  different  characters  of  the  expectoration,  in  the  succes- 
sive stages  of  the  disease,  we  recognize  the  source  of  the  principal 
varieties  of  the  pulmonary  catarrh.  The  dry  catarrh  is  that  which 
never  proceeds  beyond  the  first  stage  ;  the  pituitous  is  that  which 
stops  at  the  second ;  and  the  mucous  is  that  which,  after  passing 
through  the  two  former,  persists  in  the  third. 

Symptoms  and  progress.  The  pulmonary  catarrh  is  usually 
preceded  by  coryza,  which  is  an  affection  precisely  similar  of  the 
pituitary  membrane.  After  some  days,  or  perhaps  hours,  and, 
in  most  cases,  just  as  the  stuffing  of  the  nostrils  begins  to  yield, 
the  inflammation  reaches  the  air  passages.  Its  transmission  to 
the  larynx  is  indicated  by  a  sense  of  uneasiness  and  irritation,  or 
a  titillation  like  that  of  itching,  which  provokes  to  cough ;  and 
if  the  mucous  membrane  is  much  affected,  there   is  hoarseness, 

*  Cases  like  this  are  far  from  being  uncommon,  but  there  is  no  proof  of  the 
existence  here  as  in  the  cases  under  my  observation,  of  a  complete  obstruction 
of  the  principal  air  tube  of  one  of  the  lobes  of  the  lungs.  They  are  threfore 
not  analogous  cases,  and  consequently  cannot  exhibit  the  same  symptoms. — 
Andral.  , 

10 


74  ACUTE    Mil  ODS    CATARRH. 

and  occasionally  loss  of  voice.  When  the  inflammation  extends 
to  the  bronchi,  there  is  sometimes  a  slight  pain,  more  commonly 
a  sense  of  dryness  and  roughness,  behind  the  sternum  or  at  its 
lower  extremity.  When  the  disease  is  very  severe,  there  is 
greater,  sometimes  indeed  very  sharp,  though  transient  pain  ex- 
tending over  the  whole  chest,  particularly  after  the  fits  of  cough- 
ing. When  the  cough  is  violent,  the  patient  feels  also  pain  and 
weakness  about  the  attachments  of  the  diaphragm,  along  the 
borders  of  the  false  ribs,  and  in  the  back. 

The  cough,  at  first  dry,  is  soon  accompanied  by  a  serous  ex- 
pectoration, which  is  saltish  and  slightly  glutinous,  but  not  dis- 
tinguishable from  the  saliva  with  which  it  is  intermixed.  This. 
in  adults,  is  usually  intermixed  with  some  small  pearly  sputa 
which  are  more  or  less  tinged  with  the  black  pulmonary  matter, 
and  generally  softer  than  those  expectorated  in  the  dry  catarrh. 
As  the  disease  advances,  the  expectoration  becomes  thicker,  and 
more  yellow,  and  is  intermixed  with  particles  of  an  opaque 
whitish  color:  by  degrees  the  whole  becomes  opaque,  of  a  pale 
yellow,  or  slightly  greenish  hue,  viscid,  enclosing  air  bubbles, 
tasteless,  or  somewhat  saltish,  and  occasionally  marked  with 
dots,  or  small  streaks  of  blood.  The  cough  returns  by  fits,  and 
is  more  or  less  frequent  according  as  the  expectoration  is  copious 
or  otherwise ;  it  is  particularly  troublesome  on  waking  in  the 
morning,  and  sometimes  after  meals.  When  the  sputa  are  very 
large,  they  frequently  leave,  after  expectoration,  a  dull  pain 
about  the  root  of  the  bronchi,  indicative  of  the  place  whence 
they  have  been  detached  by  the  efforts  of  coughing.  Sometimes, 
as  the  complaint  of  the  lungs  begins  to  give  way,  an  analogous 
affection  seizes  the  mucous  membrane  of  the  intestines  and  pro- 
duces diarrhoea.* 

In  the  greater  number  of  cases,  the  foregoing  are  the  whole  of 
the  symptoms,  except  that  there  is  occasionally  a  slight  degree  of 
fever  during  the  first  few  days  :  this  is  most  perceptible  in  the 
evening,  and  terminates  towards  morning  with  a  slight  moisture 
on  the  skin,  and  a  lateritious  sediment  in  the  urine.  '  This  secre- 
tion also  sometimes  presents  a  copious  mucous  cloud  or  deposit ; 
and  this  circumstance,  together  with  the  heat  experienced  in 
passing  the  urine,  would  seem  to  indicate  an  affection  (though  a 
very  slight  one)  of  the  mucous  membrane  of  the  bladder,  of  the 

*  This  tendency  of  catarrh  always  to  descend  had  not  escaped  the  notice  of  the 
-S^and  n°  d°Ubt  gaVe  °Ccasion  t0  its  name— from  F'<"  fluo  and  Xara  dcorsum. 

This  is  a  strained  interpretation.  The  nomenclators  of  the  disease,  no  doubt 
were  satisfied  with  the  observation  of  the  discharge  flowing  downwards  from  the 

fifiuci  or  nose—  l  tutisL . 


ACUTE  MUCOUS  CATARRH.  75 

same  kind  as  that  of    the  lungs.     Saspius  etiam  in  hoc  stadio 
morbi,  seminis  deperditiones  noctu  interveniunt. 

If  the  disease  is  more  severe,  there  is  fever  constantly  present, 
usually  accompanied  by  sweating,  and  also  dyspnoea.  This  state 
may  last  some  weeks ;  and  if  the  local  affection  is  so  extensive  as 
to  occupy  the  whole  of  one  lung  and  part  of  the  other,  the  op- 
pression of  the  chest  is  considerable.  In  this  case,  the  fever  runs 
high  and  may  assume  the  characters  of  continued  fever  of  the 
severest  kind,  giving  rise  to  those  cerebral  and  intestinal  con- 
gestions, and  that  alteration  of  the  fluids,  which  usually  accom- 
pany these  affections.  This  is  the  catarrhal  fever.  When  it  is 
distinguished  by  paroxysms,  the  catarrhal  affection  appears  re- 
newed with  each  of  these ;  the  coryza,  tightness  of  the  chest, 
and  serous  expectoration,  coming  on  with  the  fit,  and  the  mucous 
sputa  re-appearing  at  its  termination. 

Occasional  causes.  The  most  common  occasional  cause  is  the 
sudden  or  long-continued  impression  of  cold  when  the  body  is 
warm.  The  reverse  of  this,  however,  is  also  a  frequent  cause, 
especially  in  spring.  This  effect  of  change  of  temperature  is 
much  more  marked  in  persons  accustomed  to  a  sedentary  and 
comfortable  or  luxurious  mode  of  living,  as  we  see  them  take 
cold  at  their  own  fire-sides,  and  even  in  their  beds,  much  more 
frequently  than  the  laboring  classes  who  are  accustomed  to 
work  in  the  open  air.  The  inhalation  of  acrid  fumes,  particu- 
larly those  of  chlorine,  vinegar,  and  other  acids,  sometimes  gives 
rise  to  pulmonary  catarrh  ;  and  it  is  remarkable  that  the  disease, 
when  produced  in  this  manner,  is  usually  slight,  and  of  much 
shorter  duration  than  when  otherwise  excited. 

Pathognomonic  signs.  There  are  none  of  the  symptoms  above 
detailed  which  can  be  considered  as  pathognomonic  of  the  dis- 
ease. Cough  is  common  to  almost  all  diseases  of  the  lungs.  The 
expectoration  is  less  equivocal,  yet  is  insufficient  to  distinguish 
pulmonary  catarrh  from  certain  cases  of  peripneumony,  pleurisy, 
or  phthisis.  The  other  symptoms  may  be  met  with  in  almost  all 
diseases.  Auscultation,  however,  either  singly  or  conjoined  with 
percussion,  furnishes  us  with  several  signs  sufficient  not  merely 
to  characterize  the  disease,  but  to  point  out  its  actual  severity, 
and  to  discriminate  it  from  all  others. 

When  the  catarrh  is  simple,  however  violent  it  may  be,  per- 
cussion yields  every  where  the  natural  sound.  At  the  invasion 
of  the  disease,  when  there  is  only  coryza,  with  hardly  any  cough, 
or  with  merely  a  slight  irritation  in  the  fauces,  the  stethoscope 
applied  to  the  chest  indicates,  even  in  this  stage,  a  rhonchus 
which  is  often  very  loud.  This  rhonchus  is  usually  sonorous 
and  deep,  (sonore- grave,)  but  sometimes  sibilous  ;  its  precise  seat 
being  indicated  by  the  attendant  vibration..    When  the  rhonchus 


76  ACUTE  MUCOUS  CATARRH. 

is  very  loud,  it  may  be  heard  (but  less  distinctly  and  without 
any  accompanying  vibration)  at  a  considerable  distance  from  its 
site  ;  and  in  this  case,  even  though  possessing  the  deepest  or 
gravest  tone  in  its  proper  site,  when  examined  at  the  remotest 
point  where  it  can  be  heard,  it  seems  to  become  sharper  and 
somewhat  like  the  sibilous  rhonchus. 

The  rhonchus  is  the  more  sonorous  and  flatter  in  proportion 
as  the  mucous  membrane  is  more  tumefied  and  its  secretion 
scanty.  When  so  strong  as  to  resemble  the  prolonged  scrape  of 
the  bow  on  a  large  violoncello-string,  or  the  note  of  the  wood- 
pigeon,  there  are  usually  redness  and  swelling  of  the  membrane 
at  the  bifurcation  of  some  of  the  principal  bronchi.  As  the 
disease  advances,  and  the  mucous  secretion  increases,  the  sound 
gradually  assumes  the  characters  of  the  guggling  or  mucous 
rhonchus,  formerly  described. 

By  means  of  this  sign  we  can  readily  ascertain  the  site  and 
extent  of  the  disease.  If  this  is  only  partial  as  is  usually  the 
case,  the  rhonchus  is  equally  partial.  The  knowledge  of  this 
fact  is  very  important,  as  the  danger  of  the  disease  is  always 
proportioned  to  the  extensiveness  of  the  local  affection.  When 
the  rhonchus  exists  in  the  whole  of  one  lung,  or  in  the  greater 
part  of  both,  the  disease  is  always  severe  ;  when  it  exists  over  the 
whole  of  both,  (which  is  only  the  case  when  catarrh  supervenes 
to  a  severe  idiopathic  fever,)  death  almost  always  follows,  except 
in  very  early  age.*f     When  the  disease  is  slight  and  confined  to  a 

*  This  seems  to  be  incorrect:  cases  are  not  uncommon  even  of  adult  persons 
being  attacked  with  acute  or  chronic  bronchitis,  and  exhibiting  in  different  parts 
of  the  chest  the  varieties  of  rhonchus  described  here  by  Laennec  :  in  no  part 
of  their  lungs  is  the  vesicular  respiration  heard,  yet  sooner  or  later  they  are 
restored  to  health.  The  existence  of  a  mucous  rhonchus  throughout  the"  pos- 
terior portion  of  both  lungs  often  accompanies  other  very  slight  symptoms. 
Individuals  may  be  found  with  little  cough,  no  oppression,  and  in  other  respects 
completely  free  from  fever,  yet  exhibiting  in  every  part  of  the  lungs  posteriorly, 
and  particularly  in  the  inferior  lobes,  the  mucous  rhonchus.  In  these  cases, 
the  bubbles  of  the  rhonchus  are  often  very  minute  and  delicate,  resembling 
very  nearly  those  of  the  crepitous  rhonchus,  and  becoming  finally  identical 
with  them.  In  cases  like  this,  we  must  not  suppose  the  existence  of  pneu- 
monia which  is  not  indicated  by  any  other  symptom.  Errors  of  diagnosis  of 
this  description  have,  notwithstanding,  been  frequently  committed  by  placing 
too  great  reliance  on  the  crepitous  rhonchus  as  a  pathognomonic  symptom  of 
inflammation  of  the  parenchyma  of  the  lungs.  Hence  the  pretended  cure  of 
pneumonia  by  the  aid  of  certain  remedies  which  had  only  pulmonary  catarrh 
to  deal  with. — Andral. 

t  It  is  very  true  that  in  severe  continued  fevers,  attended  by  great  intestinal 
disturbance,  the  bronchi  are  commonly  the  seat  of  a  catarrhal  affection  which 
is  in  general  attended  by  little  cough,  and  which  may  be  known  during  life  by 
the  existence  of  a  sibilous  rhonchus.  In  place  of  this  sibilous  rhonchus  we 
find  more  rarely  a  mucous  rhonchus  more  or  less  distinct,  according  to  the' du- 
ration of  the  disease,  and  which  is  found  principally  in  the  posterior-inferior 
parts  of  the  chest.  There  are  instances  in  these  disorders,  where  the  rhonchi 
whether  sibilous,  mucous  or  sub-crepitous,  arc  remarkable  for  their  intensity 
and  the  wide  extent  of  space  in  which  they  may  be  heard ;  wherever  the  ear 


ACUTE  MUCOUS  CATARRH.  77 

small  portion  of  the  membrane,  the  mucous  rhonchus  only  exists 
in  the  morning  previously  to  expectoration. 

One  of  the  most  remarkable  things  attending  the  stethoscopic 
exploration  of  pulmonary  catarrh,  is  the  occasional  suspension  of 
the  respiration  in  the  affected  part.  This,  which  may  be  con- 
sidered as  pathognomonic  of  the  disease,  frequently  comes  on  all 
at  once,  and  passes  off  in  like  manner,  after  coughing  or  expecto- 
ration. It  is  occasioned  by  the  temporary  obstruction  of  one  of 
the  bronchial  tubes  by  the  mucus  contained  in  it.  Sometimes 
the  respiration  is  not  entirely  suspended,  but  only  greatly  dimin- 
ished, so  as  to  be  scarcely  heard,  except  by  means  of  a  slight 
mucous  or  obscure  sibilous  rhonchus,  which  is  now  and  then  per- 
ceptible. This  rhonchus  seems  formed  by  as  small  bubbles  as 
those  of  the  crepitous,  only  tljey  are  more  isolated,  and  evidently 
produced  by  a  more  glutinous  fluid  ;  and  now  and  then  they 
give  a  slight  click,  as  of  a  valve.*  This  modified  suspension 
of  respiration  is  occasioned  by  the  intumescence  of  the  inner 
membrane  of  the  smaller  bronchi.  It  is  neccessary  to  remark,  that 
even  in  the  most  complete  suspension  of  respiration  from  the  cause 
above  mentioned,  the  sound  is  rather  masked  or  suffocated,  than 
totally  extinct,  as  in  peripneumony.  Experience  alone  can  enable 
us  to  make  the  distinction  between  these  two  negative  sensations. 
This  suspension  of  the  respiration  might  readily  mislead  an  inat- 
tentive observer,  and  induce  the  belief  of  hepatization  of  the  lung 
or  effusion  into  the  pleura :  but  percussion  removes  at  once  all 
doubt,  by  eliciting,  in  the  case  of  catarrh,  the  natural  sound  from 
the  part  destitute  of  respiration.  It  is  indeed  true,  that  this  cir- 
cumstance will  not  distinguish  this  disease  from  pneumo-thorax 
and  emphysema  of  the  lungs  ;  but  we  shall  hereafter  find  suffi- 
cient distinctive  signs  for  these  diseases  also.f 

is  applied  they  are  audible.  Yet  in  such  cases,  the  disorder,  in  which  the 
bronchial  congestion  is  but  one  element,  may  terminate  favorably.  In  allowing 
with  Laennec  that  in  violent  fevers,  the  rhonchi  are  often  heard  through  the 
whole  extent  of  the  lungs,  I  cannot  agree  with  him  that  rhonchus  so  extensive 
never  occurs  except  in  these  disorders.  Where  is  the  physician  who  has  not 
found  this  rhonchus  taking  the  place,  every  where,  of  the  vesicular  respiration 
in  a  great  number  of  cases  of  simple  bronchitis,  where  no  other  disease  ex- 
isted ? — Aniral. 

*  It  is  this  obscure  mucous  rhonchus  which  has  led  some  persons  to  believe 
that  the  crepitous  rhonchus  was  not  confined  exclusively  to  pneumonia.  It  is, 
however,  proper  to  remark,  that  a  very  acute  pulmonary  catarrh  affecting  the 
minutest  bronchi,  is  very  nearly  allied  to  pneumonia,  and  it  is  reasonable  that 
there  should  be  a  corresponding  approximation  of  the  characters  of  the  sounds 
in  the  two  cases  ;  still  the  two  rhonchi  must  not  be  confounded. — (M.  L.) 

t  The  partial  suspension  of  the  respiratory  sound  in  pulmonary  catarrh  is  always 
momentary.  Most  commonly  if  we  keep  our  stethoscope  on  the  same  spot  for 
a  minute  or  two,  we  shall  find  the  respiration,  which  had  previously  been 
weak  or  almost  extinct,  become  all  at  once  pcurile,  and  vice  versa.  The  same 
is  true  of  the  rhonchus,  which  is  found  to  change  its  character  and  its  site  every 
instant,  becoming,  by  turns,  sonorous,  sibilous,  mucous  and  this   latter  varying 


78  ACUTE  MUCOUS  CATARRH. 

Treatment.  Although  this  disease  consists  in  an  inflamma- 
tion of  the  mucous  membrane  of  the  lungs,  bleeding  is  rarely 
useful  in  it,  except  in  very  robust  subjects,  or  where  the  symp- 
toms are  so  severe  as  to  threaten  peripneumony,  or  where  there 
is  blood  in  the  expectoration.  Accordingly,  this  measure,  with  the 
exceptions  just  named,  has  always  been  rejected  by  good  practition- 
ers, as  rendering  the  disease  of  longer  duration,  and  as  diminish- 
ing and  sometimes  checking  the  expectoration.  Leeching  has  the 
advantages  and  disadvantages  of  venesection,  only  in  a  less  degree. 
Cupping  is  in  general  more  useful.  By  using  many  glasses,  and  yet 
taking  away  only  a  small  quantity  of  blood  at  once,  and,  more  par- 
ticularly, by  keeping  the  glasses  applied  for  a  considerable  time, 
so  that  the  tumefaction  produced  by  them  does  not  too  speedily 
subside,  we  frequently  obtain,  in  the,  severer  cases,  marked  relief 
of  the  oppression  and  other  symptoms.  Blisters  are  not  so  bene- 
ficial. Sometimes  they  are  hurtful,  producing  an  increase  of 
fever,  and  augmenting  the  bronchial  congestion :  this  is  more 
especially  the  case  when  they  are  applied  during  the  acute  stage, 
and  to  the  chest.  When  the  disease  has  been  of  some  continu- 
ance, and  there  seems  reason  to  apprehend  its  becoming  chronic, 
or  if  it  be  supposed  to  be  grafted  on  a  latent  tuberculous  state  of 
the  lungs, — in  either  of  these  cases  a  blister  to  the  arm  may  be 
useful,  particularly  if  the  discharge  is  kept  up  for  some  time.  In 
the  case  of  females,  it  is  in  general  preferable  to  apply  the  blister 
to  the  thigh,  as  being  less  apt  to  occasion  suppression  of  the  c'at- 
amenia  in  this  situation.  Emetic  medicines  have  been  much  em- 
ployed in  this  disease,  more  particularly  ipecacuan  and  the  emetic 
tartar.  They  have  been  had  recourse  to  either  with  the  view  of  pro- 
ducing vomiting  or  nausea,  or  given  in  doses  so  small  as  not  to 
occasion  any  perceptible  effect,  but  with  the  intention  of  favoring 
expectoration,  or  determining  to  the  skin.  There  can  be  no  doubt 
that  vomiting  is  often  beneficial  in  the  outset  of  catarrh,  provided 
no  inflammatory  state  of  the  stomach  exists.  It  is  also  necessary 
where  the  disease  is  complicated  with  a  bilious  affection,  as  is 
commonly  the  case  in  seasons  when  the  latter  class  of  disorders 
prevails.  The  tendency  of  vomiting  to  produce  moisture  on  the 
skin,  and  to  facilitate  expectoration,  is  well  known  :  but  the  benefi- 
cial influence  of  the  same  medicines  given  as  incisives,  that  is,  in 
small  doses, — or  of  the  other  simple  nauseating  preparations  occa- 
sionally substituted  for  these,  such  as  the  oxymel  of  squills,  kermes 
mineral,  &c. — is  much  less  certain.  The  efficacy  of  emetics  is 
much  greater  in  the  case  of  children,  who  are  in  general  found  to 
bear  this  kind  of  treatment  better  than  adults.  To  the  former  they 
may  be  given,  without  inconvenience,  every  other  day,  or  even 

in  its  peculiar  characters.     This  variableness  of  the  auscultatory  phenomenon 
is  strikingly  characteristic  of  pulmonary  catarrh.— (M.  L.) 


ACUTE    MUCOUS    CATARRH.  79 

every  clay  for  a  week  or  more  ;  and  this  practice  affords  the  best 
guard  against  the  catarrhs  of  early  infancy  degenerating  into  the 
hooping  cough. 

It  is  usual  to  prescribe  through  the  whole  course  of  catarrh,  va- 
rious emollient  drinks,  of  which  sugar,  gum,  and  infusions  of  the 
most  inert  plants,  form  the  basis  ;  and  as  most  cases  of  ihe  dis- 
ease are  only  slight,  these  constitute,  in  general,  the  sole  treat- 
ment :  or  it  may  be  said  there  is  no  treatment ;  since  these  sub- 
stances, rather  alimentary  than  medicinal,  are  in  fact  mere  pre- 
texts of  the  expectant  method.  This  truth  is  known  to  the  vul- 
gar, and  is  well  embodied  in  the  addage,  "  a  cold  well  nursed  lasts 
forty  days,  and  a  cold  not  nursed  lasts  six  weeks."  And  even 
this  is  perhaps  according  more  to  the  treatment  than  it  deserves : 
but  in  general  the  disease  is  too  slight  to  require  one  more  ener- 
getic. 

There  remains  to  be  noticed  another  mode  of  treating  catarrh, 
equally  popular,  and  practised  from  time  immemorial,  although 
less  countenanced  by  physicians,  probably  from  apprehension  of 
its  ill  effects, — I  mean  the  use  of  spirituous  preparations,  such 
as  warm  wine,  burnt  brandy,  and  punch.  This  plan  is  unques- 
tionably eminently  successful  in  a  vast  number  of  cases.  By  it 
we  frequently  observe  a  cold,  which  seemed  to  threaten  great  se- 
verity, cured  all  at  once  in  the  course  of  a  single  night.  The 
fear  of  converting  catarrh  into  peripneumony,  is  no  doubt  what 
prevents  this  plan  being  commonly  adopted  by  practitioners; 
and  I  must  confess  that  the  same  reasons  influenced  my  own 
conduct  formerly.  My  experience,  however,  has  given  no  coun- 
tenance to  such  apprehensions ;  and  I  accordingly  now  always 
employ  this  kind  of  treatment  where  there  exists  no  clear  contra- 
indications, such  as  an  inflammation  of  the  stomach  or  intestines, 
or  a  strongly-marked  sanguine  constitution,  or  one  easily  excited 
by  spirits,  or  a  rlisease  so  violent  as  to  give  reason  to  apprehend 
the  supervention  of  the  peripneumony  or  croup.  My  plan  is  to 
give  to  the  patient  at  bed-time,  an  ounce  or  an  ounce  and  a  half 
of  good  brandy,  in  double  the  quantity  of  an  infusion  of  violets, 
made  very  hot  and  sweetened  with  syrup  of  marsh  mallows. 
This  dose  is  usually  followed  by  a  copious  perspiration  towards 
morning  ;  but  frequently  the  disorder  is  cured  without  any  per- 
spiration. If  this  is  not  the  case,  the  same  plan  is  followed  for 
several  nights  successively.  It  is  particularly  in  the  very  onset  of 
catarrh  that  this  treatment  is  most  successful ;  it  is  much  less  so 
after  the  supervention  of  the  loose  expectoration.* 

*  Or  opium  may  be  substituted  for  alcohol.  An  ounce  of  syrup  of  poppies  or 
of  opium,  taken  ut  one  dose  at  bed-time,  in  a  cup  of  very  hot  tisan,  excites  per- 
spiration even  more  certainly  than  the  author's  punch,  and  has  the  advantage, 
moreover,  of  soothing  the  cough  and  promoting  sleep.  This  remedy,  however, 
like  punch,  must  be  used  with  much  caution  and  reserve. — (M.  L.) 


80  CHRONIC    MUCOUS    CATARRH. 

I  do  not  believe  that  this  stimulant  treatment  can  be  safely 
applied  (as  it  is  by  the  common  people)  to  diarrhoea,  even  when 
arising  from  cold,  and  appearing  to  differ  from  pulmonary  catarrh 
only  in  its  seat ;  since  I  have  witnessed  the  supervention  of  peri- 
tonitis, severe  dysentery,  and  arachnitis,  to  fluxes  suppressed  by 
the  use  of  hot  wine  and  spices.  This  imprudent  extension  of  a 
useful  practice  has  originated  in  the  expectation  of  curing,  by 
producing  sweat,  all  other  diseases,  as  well  as  catarrh,  which 
manifestly  originate  from  cold ;  a  theory,  by  the  way,  derived 
from  high  medical  authority  (Van  Helmont)  ;  as  is  the  case  with 
all  the  medical  prejudices  and  errors  current  among  the  vulgar.* 

Sect.  II.   Of  the  chronic  mucous  catarrh. 

The  anatomical  characters  of  the  chronic  mucous  catarrh,  are 
nearly  the  same  as  those  of  the  acute,  insomuch  that,  in  the 
majority  of  cases,  it  would  not  be  possible  to  distinguish  the  two 
diseases  in  the  dead  body.  It  may,  however,  be  observed,  that, 
in  the  chronic  affection,  the  membrane  is  more  frequently  of  a 
violet  color,  and  irregularly  marked  here  and  there  with  spots  of 
a  paler  or  darker  hue,  while  in  the  acute,  the  red  is  brighter,  and 
verging  more  towards  purple  or  brown.  But  these  shades  of  dif- 
ference are  frequently  inappreciable,  owing  to  the  vascular  con- 

*  A  catarrh  or  common  cold,  as  it  is  called,  is  of  such  every  day  occurrence, 
and  in  general  of  such  moderate  severity,  as  seldom  to  come  within  the  pale  of 
formal  medical  treatment.  The  very  tolerable  amount  of  its  evils,  and  the  con- 
fident expectation  of  being  speedily  freed  even  from  these,  by  the  simple  pro- 
cesses of  nature,  no  doubt  render  it  frequently  of  long  duration,  when  it  might 
be  removed  very  speedily,  and  occasion  many  remedial  measures  of  well-known 
efficacy  to  fall  into  neglect.  Of  this  kind  is  the  inhalation  of  the  steam  of  warm 
water,  conjoined  with  the  internal  use  of  diaphoretics  and  the  application  of 
steam  to  the  surface  of  the  body,  formerly  recommended  by  Mr.  Mudge,  and 
described  in  his  very  excellent  Essay,  entitled  "  A  Radical  and  Expeditious 
Cure  for  a  recent  Catarrhous  Cough,"  2nd  Ed.  London,  177J).  Whoever  will 
be  at  the  expense  of  procuring  the  Inhaler,  and  will  take  the  trouble  to  use  his 
process  at  the  exact  period  of  the  disease,  (i.  e.  at  the  very  onset.)  and  precisely 
in  the  manner  recommended  by  him,  at  page  134,  et  seq.,  will,  Idoubt  not,  find 
therein  a  remedy  at  least  as  efficacious  and  speedy,  and  certainly  more  safe,  than 
the  spirituous  treatment  of  our  author.  But,  perhaps,  after  all,  for  those  who  have 
leisure  for  such  luxurious  medication,  and  who  do  not  consider  such  a  restrictive 
mode  of  cure  as  worse  than  the  disease,  the  safest  and  surest  remedy  is  to  lie  in 
bed  and  live  on  slops  for  a  day  or  two. 

A  mode  of  treatment  of  recent  catarrh,  of  a  somewhat  novel  character,  has 
lately  been  promulgated  by  Dr.  Charles  Williams,  in  the  Cyclopaedia  of  Practi- 
cal Medicine  (vol I  i.  Art.  Coryza.)  This  consists  essentially  in  the  total  absti- 
nence from  liquids.  Dr.  Williams  speaks  most  confidently  of  the  efficacy  of 
this  plan,  and  I  can  myself  corroborate  his  statements  as  far  as  a  few  trials  in 
my  own  case  go.  «  To  those  (says  Dr.  Williams)  who  have  the  resolution  to 
bear  the  feeling  of  thirst  for  thirty-six  or  forty-eight  hours,  we  can  promise  a 
pretty  certain  and  complete  riddance  of  their  colds,  and,  what  is  perhaos  more 
important,  a  prevention  of  those  coughs  which  commonly  succeed  to  them     Nor 

?o.  f  8"ffenn,S  from  thirst  nea'ly  so  great  as  might  be  expected."     (Loc   Cit   d 
Ibl) — Transl.  K  " 


CHRONIC    MUCOUS    CATARRH.  81 

gestiou  Occurring  after  death,  and  which  always  exists  in  the 
lungs,  in  a  greater  or  less  degree.  And  it  is  by  no  means  rare, 
particularly  in  old  subjects,  and  in  catarrhs  of  long  standing,  to 
find  Ihe  membrane  very  pale  throughout,*  or  of  a  yellowish  color, 
willi  a  scarcely  perceptible  shade  of  red.f  The  chronic  catarrh 
is  sometimes  accompanied  with  a  general  or  partial  dilatation  of 
the  bronchi,! — an  affection  which  I  shall  notice  hereafter. 

The  expectoration  in  the  chronic  disease  is  sometimes  pre- 
cisely similar  to  that  of  the  latter  stage  of  the  acute  ;  but  most 
commonly  it  is  less  glutinous,  more  opaque,  and  nearly  puriform. 
Occasionally,  it  is  of  a  dirty  greyish  or  greenish  hue,  from  an 
admixture  of  the  black  pulmonary  matter ;  and  in  this  state  it 
cannot  be  distinguished  from  the  expectoration  of  phthisis. 
.Sometimes,  but  rarely,  it  is  tinged  with  blood,  an  appearance 
which  generally  indicates  cither  a  local  fullness  of  the  vessels,  of 
little  consequence,  or  the  supervention  of  the  acute  to  a  chronic 
affection.  It  is  usually  inodorous,  but  sometimes  becomes  more 
or  less  fetid,  and  assumes  the  smell  as  well  as  the  other  physical 
qualities  of  the  different  kinds  of  pus :  having,  at  one  time,  the 
smell  of  good  pus  from  a  recent  wound ;  at  another,  the  strong 
odor  of  the  contents  of  a  large  abscess,  and  occasionally  ap- 
proaching the  gangrenous  fetor.  After  a  period,  this  bad  smell 
disappears,  and   may  return    perhaps  several  times  in    the  course 

*  It  is  in  cases  of  this  description,  which  are  more  common  than  many  phy- 
sicians arc  disposed  ii>  think,  that  the  term  bronchitis  becomes  altogether  im- 
proper. There  is  here  no  longer  any  inflammatory  action  ;  if  any  existed  at 
the  commencement,  it  lias  long  since  disappeared.  All  we  can  discover  is  an 
alteration  in  the  quantity  and  quality  of  the  mucus  secreted  from  the  inner 
surface  of  the  bronchi.  This  is  a  lesion  of  secretion  ;  ami  it  is  mere  hypothe- 
sis contradicted  !>y  facts,  to  suppose,  as  some  do,  that  every  change  in  the  secre- 
tion, is  the  result  of  inflammation  or  irritation  in  the  secreting  membrane. 
Thc>  derangement  in  the  process  by  which  the  secreted  matter  is  separated  from 
the  Moo, I,  should  l>c  regarded  as  a  morbid  affection,  independent  and  primitive, 
like  that  of  hyperemia  itself;  and  as  this  may  be  accompanied  by  a  lesion  of 
secretion,  so  on  the  other  hand,  a  lesion  of  secretion  may  be  attended  by 
hyperemia,  which  in  such  cases,  is  only  a  consecutive  phenomenon.  These 
two  -.irts  of  lesions,  .therefore,  may  become  bj  turns  the  cause  and  effect  of 
each  other.  Every  mucous  membrane  may  offer  examples  of  these  fluxes,  both 
acute  and  chronic,  which,  in  regard  to  symptoms  attending  them,  the  treatment 
they  receive,  and  tin-  anatomical  lesiorts  consequent  upon  them,  constitute 
morbid  conditions  altogether  distinct  from  inflammation" or  hyperemia.  Thus 
bronchorrbcea  is  a  different  thing  from  bronchitis,  in  the  same  manner  as  gas- 
trorrhoea  and  enterrhcea,  although  sometimes  closely  connected  with  gastritis  or 
enteritis,  pel  ought  to  he  distinguished  from  them.— Andrul. 

I  Baj  le,  Reeherchis  sur  In  Phthisie,  obs.  49;  Andral,  Clin.  Med.  t.  ii.  obs.  16. 

X  The  bronchi  not  only  become  dilated  in  many  cases  of  chronic  pulmonary 
catarrh,  but  they  also  undergo  in  this  disorder,  an  alteration  of  an  opposite 
kind.  They,  shrink  and  even  become  obliterated  in  a  certain  number-of  their 
divisions;  and  however  trifling  this  conjraction  may  be,  it  gives  rise  to  symp- 
toms as  important  as  those  accompanj  ing  the  dilatation  of  these  organs.  Pecu- 
liar  symptoms  arc  also  discovered  by  the  stethoscope.  We  shall  have  occasion 
again  to  refer  to  this  class  of  bronchial  alterations,  which  I  have  pointed  put  as 
one  of  tin  possible  effects  of  pulmonary  catarrh.— Andral. 
11 


82  CHRONIC  MUCOUS  CATARRH. 

of  the  year.  The  quantity  of  the  expectoration  is  more  variable 
from  day  to  clay,  but  almost  always  greater  than  in  the  acute 
disease.  It  not  unfrequently  amounts  to  one  or  two  pounds  in 
the  course  of  twenty-four  hours.  It  is  increased  on  every  fresh 
attack  of  cold ;  or  rather  the  mucous  secretion  is  at  first  less, 
with  more  watery  discharge,  and  then,  after  a  few  days,  becomes 
more  copious.  In  some  rare  instances  it  becomes  all  at  once, 
and  usually  without  obvious  cause,  so  very  abundant  and  puri- 
form,  as  to  lead  to  the  suspicion  of  a  vomica  being  opened  into 
the  bronchi ;  a  mistake  which  is  more  likely  to  happen  on  ac- 
count of  the  oppression  which  usually  precedes  and  accompanies 
this  state.  The  oppression,  however,  is  owing  merely  to  a 
great  increase  of  the  morbid  secretion.  Nevertheless  when  the 
expectoration  happens  to  be  difficult,  from  weakness  or  other- 
wise, the  case  just  mentioned  forms  one  of  the  varieties  of  the 
suffocative  catarrh.* 

Haemoptysis  of  any  degree  of  severity,  is  of  much  rarer  occur- 
rence in  the  simple  chronic  catarrh  than  in  persons  with  no  appa- 
rent disease.f 

The  disease  I  have  been  describing  is  very  common  in  old 
persons,  and  is  indeed  the  most  frequent  infirmity  of  age.  It  is 
not  very  rare  even  in  infancy,  particularly  after  hooping-cough  ; 
and  in  this  case  it  sometimes  persists  through  the  course  of  a  long 

*  A  remarkable  case  of  this  kind  is  given  by  Andral,  torn.  ii.  obs.  17. — Author. 

t  Profuse  haemoptysis  is  indeed  uncommon  with  individuals  who  have  only 
a  simple  chronic  catarrh  of  the  lungs.  I  have  met  with  so  few  cases,  although 
my  attention  has  been  particularly  directed  to  this  point,  that  whenever  I  find 
an  abundant  spitting  of  blood  in  the  course  of  an  affection  of  this  sort  which 
has  continued  long,  I  regard  it  as  highly  probable  that  tubercles  have  formed  in 
the  lungs,  notwithstanding  the  flattering  character  of  the  other  symptoms. 
I  have  nevertheless  cited  in  my  Clinique  Medicate,  some  contradictory  cases  as 
exceptions.  I  will  repeat  here  the  notice  of  a  female,  aged  56,  who  in  the 
course  of  a  bronchitis  of  two  months' standing,  and  which  did  not  hinder  her 
from  pursuing  her  usual  occupations  out  of  doors,  was  suddenly  attacked  while 
in  church,  with  a  profuse  haemoptysis.  A  large  quantity  of  blood  was  raised  at 
the  first  attack;  the  following  days  she  continued  to  expectorate  blood  freely, 
and  at  the  end  of  ten  days  the  bleeding  ceased.  The  patient  was  of  a  delicate 
constitution  and  habitually  pale ;  she  was  bled  once,  and  leeches  were  once 
applied  around  the  anus  ;  she  was  confined  to  her  bed,  and  kept  upon  a  strict 
diet  for  some  days.  The  cough  lasted  for  some  time  after  the  disappearance  of 
the  haemoptysis,  and  finally  ceased  entirely.  Since  then,  nine  years  have  passed, 
and  the  haemoptysis  has  not  reappeared  :  this  alone  would  be  no  way  extraordi- 
nary, but  in  all  this  time  the  patient  has  not  been  known  to  cough  seriously, 
nor  exhibit  any  signs  of  pectoral  disease.  She  breathes,  freely,  and  no  trace  of 
any  lesion  of  the  respiratory  organs  can  be  discovered  by  auscultation. 

I  have  witnessed,  as  has  our  author,  cases  of  profuse  haemoptysis  occurring 
in  individuals,  who  up  to  that  moment,  had  exhibited  no  signs  of  disease  in  the 
air  tubos,  and  who  were  attacked  in  the  midst  of  the  most  perfect  health. 
Some  of  these  recovered  perfectly,  and  now  show  no  marks  of  pulmonary 
affection.  For  the  most  part,  however,  it  is  otherwise  ;  in  the  far  greater  num- 
ber of  cases,  this  haemoptysis,  whatever  may  have  been  formerly  Hie  apparent 
soundness  of  the  lungs,  is  the  prelude  of  decay  more  or  less  rapid  and  a  si<ni 
of  the  development  of  tubercles  in  the  lungs.—  Andral. 


CHRONIC    MUCOUS    CATARRH.  83 

life*  It  seldom  begins  in  the  middle  period  of  life.  The  repul- 
sion of  cutaneous  eruptions,  acute  or  chronic,  and  the  suppression 
of  an  habitual  discharge,  have  frequently  a  decided  influence  in 
developing  this  disorder,  as  well  as  many  others. 

Symptoms  and  progress.     This  disease  in  most  instances  suc- 
ceeds a  severe    attack  of  the  acute  catarrh  : — the   cough  and  ex- 
pectoration  continuing  after  the  fever    has  altogether   subsided ; 
or  the  fever  continuing   in  so  slight  a  degree   as  only  to  be    per- 
ceptible   towards  evening,  or    merely  during  an   increase  of  the 
complaint.     The  appetite    and  strength    return,  but   the    patient 
commonly   loses    a  little  flesh,   and   remains   paler    than   usual. 
During  repose,  there  is  no  oppression  on  the  chest,  but   exercise 
soon  brings   on    dyspnoea.       Sometimes   after  continuing  several 
months,  or  even  one   or    two  years,  the    disease  gradually  and 
entirely  passes    off.     This  more   particularly  happens    in    young 
subjects.     More   commonly,  however,  the  cough   and  expectora- 
tion diminish,  or    entirely  disappear,  during  summer  only,  and 
re-appear  in  winter.       In  this  case,  in    the  intervals   of  obvious 
disease   there   still  remains    that  variety  of  the  complaint  which 
will    afterwards   be  described  under    the  name  of  the  dry  latent 
catarrh.     The    return  of  the    complaint   in  winter    is   frequently 
attended  by  fever,    particularly  if  the  expectoration    is   copious ; 
and  after  several   renewals  of  this    kind,  it   terminates  in   a  con- 
tinued mucous    catarrh.      In  this  state,    the  pulse  and    heat  of 
skin  remain  for  the  most  part  natural,  notwithstanding  the  great 
expectoration    which    weakens  and   emaciates  the    patient.      In 
some  rare    cases,  hectic  fever  comes  on,  with    rapid  emaciation, 
and  the  disease  terminates  fatally,  with    all  the  usual  symptoms  of 
phthisis  pulmonalis.*     In   fact,  the  most  perfect  similarity  exists 
between  the  two  diseases,  as  far  as  regards  the  expectoration,  the 
emaciation,  and  all    the  other  general    symptoms.     Percussion  in 
this  case  cannot  remove  the   difficulty,  as  the  chest  sounds  quite 
well  in  many  consumptive  patients.     The  indications  afforded  by 
the  stethoscope  are  much  more  to  be  depended  on.     In  such  cases, 
if,  upon  properly  examining  a  patient,  at  different  hours,  and  for 
a  certain    length  of  time,  we   find  neither   pectoriloquy,  nor  the 
guagling   produced    by    softened    tubercles,    nor   the   cavernous 
respiration  of  tuberculous   excavations ;    nor  the  permanent  ab- 
sence of  respiration  in  certain  places  from  tuberculous  indurations 
of  some  extent,  we   have  a  strong  presumption  that   the  disease 
is  merely  chronic    catarrh  ;    and  if  the  same    results  uniformly 
present  themselves  after  an  attendance  of  soi^e  time,  (say  two  or 
three  months,)  our  presumption  is  converted   into  certainty.     In 
these  cases,  the  stethoscope  gives*  no  other  signs  than  a  mucous 

See  Bayle's  Reckerches  sur  \a  Phthisic,  p.  75,  and  cispc  48  and  V.) — Author 


84  CHRONIC  MUCOUS  CATARRH. 

rhonchus,  sometimes  indeed  pretty  loud  and  abundant,  but  very 
rarely  continuous,  and  still  more  rarely  general  over  the  chest. 
Very  commonly  we  can  hear  distinctly  the  sound  of  respiration 
notwithstanding  the  rhonchus ;  and  there  is  hardly  ever  observed 
that  total  suspension  of  respiration  which  occurs  in  the  acute  dis- 
ease, unless  indeed  there  should  happen  to  co-exist  with  the  chro- 
nic, a  dry  or  pituitous  catarrh,  with  intense  congestion  of  some 
portion  of  the  mucous  membrane.  It  even  frequently  happens 
that  the  respiration  becomes  puerile  over  nearly  the  whole  lungs, 
in  these  chronic  catarrhs,  while  at  the  same  time,  there  exists  a 
continual  dyspnoea,  occasionally  aggravated  to  violent  paroxysms, 
even  in  a  state  of  quietude.  This  constitutes  the  humid  asthma ' 
of  practitioners. 

Treatment.  The  treatment  most  in  use  for  this  complaint, 
particularly  that  of  old  persons,  consists  in  the  establishment  of  a 
permanent  drain  in  the  arm  or  thigh,  and  the  use  of  certain  aro- 
matic bitters,  or  of  other  plants  nearly  inert,  such  as  hyssop,  hore- 
hound,  ground  ivy,  sage,  veronica,  &c.  If  the  expectoration  is 
suspended,  the  oxymcl  of  squills,  or  kermes  mineral,  in  small 
doses,  is  prescribed ;  and  if  the  cough  becomes  hard,  and  returns 
by  fits,  some  slight  paregorics  are  ordered.  This  kind  of  treat- 
ment is  simply  expectant ;  although  it  is  applied  to  a  chronic 
disease,  which  far  from  tending  naturally  towards  a  cure,  grows 
worse  in  proportion  as  it  becomes  ancient,  and  as  the  age  of  the 
subject  increases. 

It  must  be  admitted  that  there  are  cases,  in  which  the  long 
continuance  of  the  disease,  and  the  age  and  debility  of  the  pa- 
tients, afford  slight  grounds  for  hope  from  a  more  active  mode 
of  treatment ;  but  there  are  many  others,  on  the  other  hand,  in 
which  the  practitioner  too  soon  despairs  of  success,  and  conse- 
quently renounces  the  use  of  means  which  are  really  efficacious. 
Among  these  means,  there  is  no  one  more  frequently  useful  than 
emetics,  repeated  according  to  the  patient's  strength  and  his 
power  of  supporting  their  action.  I  have  cured,  in  this  way, 
catarrhs  of  very  long  standing  in  old  persons,  and  still  more  in 
adults  and  children.  In  the  case  of  an  old  lady  of  eighty-five, 
who  had  labored  under  a  chronic  catarrh  for  eighteen  months, 
with  an  expectoration  amounting  to  two  pounds  daily,  I  pre- 
scribed fifteen  emetics  in  one  month,  and  with  complete  success, 
as  the  patient  lived  eight  years  afterwards  free  from  the  com- 
plaint. After  the  use  of  emetics,  tonics  given  in  small  doses  are 
often  useful,  such  as  the  bark,  and  other  bitters,  and  prepara- 
tions of  iron :  these  frequently  carry  off  the  remains  of  the  com- 
plaint entirely,  or  greatly  moderate  it. 

Spirituous  preparations,  and    particularly    punch,  sometimes 
succeed  perfectly  in  the  same  case :  but  it  is  necessary  to  con- 


CHBONIC    MUCOUS    CATARRH.  85 

tinue  their  use  much  longer  than  in  the  acute  disease.  The  bal- 
sams are  frequently  equally  beneficial,  when  the  stomach  will 
bear  them ;  but  they  must  be  given  in  a  larger  dose  than  is  usual. 
The  balsams  of  tolu  and  capaiba,  as  also  turpentine,  should  be 
given  in  a  dose  of  from  eighteen  to  thirty-six  drops  daily,  and 
sometimes  in  still  larger  quantity.  The  internal  use  of  tar  water, 
as  the  ordinary  drink,  has  sometimes  proved  successful,  as  has 
also  the  inhalation  of  the  fumes  of  this  substance  either  simply 
or  mixed  with  water,  diffused  in  the  patient's  chamber.* 

*  The  attention  of  practitioners  in  this  country,  was,  a  few  years  since,  more 
particularly  called  to  the  use  of  the  balsam  of  copaiba,  in  chronic  inflammation 
of  the  bronchi,  by  Dr.  Armstrong.  In  his  work  on  Scarlet  Fever,  &c.  page 
271,  2nd.  ed.  he  speaks  highly  of  its  beneficial  effects  in  this  disease.  He  says, 
that  it  seems  to  exert  a  specific  influence  over  the  mucous  membrane  of  the 
bronchi,  obviously  and  quickly  lessening,  in  many  cases,  the  expectoration, 
cough,  and  irritation.  He  however  recommends  it  in  much  larger  quantity  than 
even  our  author,  viz.  in  doses  of  about  thirty  or  forty  drops  three  times  a  day, 
and  gradually  increased  afterwards,  until  sixty,  eighty,  or  more  drops  betaken 
at  each  time.  I  am  sorry  to  say  that  I  have  not  derived  the  same  benefit  from 
the  use  of  this  medicine.  My  own  experience  accords  more  nearly  with  that  of 
Dr.  Hastings,  as  stated  in  his.work  on  the  inflammation  of  the  mucous  mem- 
brane of  the  lungs,  page  304.  "  Whenever  there  is  much  fever,"  says  Dr.  H., 
"  it  appears  to  be  increased  by  this  remedy,  and  it  does  not  always  allay  the 
cough  or  alter  the  expectoration.  It  frequently  disagrees  with  the  stomach, 
when  given  in  sufficient  doses  to  benefit  the  pectoral  symptoms,  and  sometimes 
a  diarrhoea  comes  on  under  its  use.  Occasionally  it  produces  all  these  trouble- 
some effects  without  relieving  the  cough."  A  circumstance,  not  much  noticed 
by  these  writers,  and  which  renders  all  such  plans  of  treatment  nugatory,  is  the 
frequent  co-existence,  especially  in  old  persons,  of  a  similar  condition  of  the 
mucous  membrane  of  the  upper  portions  of  the  alimentary  canal.  In  this  com- 
plication every  thing  stimulating,  whether  as  food  or  medicine,  is  decidedly  in- 
jurious; while  the  most  remarkable  benefit  is  derived  from  such  mild  regimen 
as  the  obvious  condition  of  the  membrane  indicates.  This  is  not  the  place  to 
inquire  into  the  rationale  of  symptoms  in  such  cases,  or  whether  the  affection  of 
either  of  the  two  portions  of  the  same  membrane — the  pulmonary  and  gastric — 
can  be  considered  as  the  cause  of  the  other :  it  is  sufficient  for  our  present  pur- 
pose to  be  assured  of  the  fact  of  the  co-existence  ;  and  it  is  highly  necessary  to 
keep  it  in  mind  in  our  practice.  See  Dr.  Fothergill's  paper  on  the  use  of  bal- 
sams, vol.  ii.  p.  115. 

The  inhalation  of  watery,  and  also  resinous  vapors  in  diseases  of  the  lungs  is 
of  very  ancient  date.  In  Bonnet's  Theatrum  Tabidorvmi,  we  find  an  account  of 
cases  treated  in  this  manner,  together  with  delineations  of  the  fumigating  appa- 
ratus, and  receipts  for  the  materials  used.  See  chap,  xxviii.  De  /mlituum  et 
suffituum  admihistrafione.  Mr.  Mudge,  in  the  work  formerly  quoted,  page  80, 
mentions  a  case  of  apparent  consumption,  wherein  much  benefit  was  derived 
from  the  inhalation  of  the  vapor  of  resin.  But  it  is  to  Sir  Alexander  Crichton 
that  we  are  indebted  for  the  introduction  of  the  vapor  of  boiling  tar  as  a  reme- 
dial agent.  This  author  first  called  the  attention  of  English  practitioners  to  the 
employment  of  tar  vapor  as  a  cure  for  consumption,  in  a  small  pamphlet,  pub- 
lished in  L817:  and  endeavored  to  impress  the  practice  more  particularly  on 
their  notice  by  a  larger  work  "  On  the  treatment  and  cure  of  several  varieties  of 
consumption, "  in  1823.  In  our  present  state  of  improved  knowledge  respecting 
the  pathology  of  phthisis  pulmonalis,  it  is  hardly  necessary  to  say  that  the  pro- 
posal to  cure  this  disease  by  such  means  would  now  appear  idle.  It  no  doubt 
originated  from  false  and  fallacious  experience,  supported  by  the  well  known 
difficulty  of  discriminating  certain  cases  of  chronic  bronchitis  from  true  phthisis. 
A  severe  examination  of  all  the  trials  made  with  this  agent,  including  even 
those  recorded  by  Sir  A.  Crichton  himself,  lead  to  the  conclusion  that  it  is  in 


86  CHRONIC    MUCOUS    CATARRH. 

When  an  acute  catarrh  supervenes  to  the  chronic  disease,  we 
are  sometimes  obliged  to  have  recourse  to  the  means  already  no- 
ticed when  treating  of  the  former,  particularly  blisters,  cupping, 
and  other  derivatives  ;  but  in  the  simply  chronic  affection  I  have 
never  found  either  blisters  or  issues  of  any  benefit.  On  the  con- 
trary, in  this,  as  in  many  other  chronic  complaints,  I  am  con- 
vinced these  are  only  one  more  evil  in  addition  to  those  already 
existing.  It  would  no  doubt  be  imprudent  to  suppress  a  drain 
of  this  kind  when  it  had  existed  for  several  years  ;  but  I  must 
think  that  it  is  not  only  prudent  but  humane  to  prevent  these 

chronic  catarrh  or  bronchitis  only,  that  this  practice  has  been  at  all  beneficial. 
Its  indiscriminate  employment  has  proved  it,  as  might  have  been  anticipated 
to  be,  injurious  in  true  phthisis,  while  its  limited  use  has  certainly  been  bene- 
ficial in  many  cases  of  the  chronic  mucous  catarrh.  Dr.  Hastings  says,  that  in 
this  disease  it  seems  to  assist  other  remedies  in  restoring  the  mucous  membrane 
to  its  healthy  secretion  ;  and  in  some  very  obstinate  cases  the  inhalation  alone 
has  appeared  to  remove  the  diseased  action  in  it.  He  adds,  however,  that  in 
other  instances  the  inflammation  has  been  aggravated  and  rendered  more  acute 
by  it.  He  sums  up  the  result  of  his  experience  of  this  remedy  in  chronic  ca- 
tarrh in  the  following  words  :  "When  the  habit  of  body  is  irritable,  and  the 
inflammation  at  all  active,  the  symptoms  arc  inareased  by  its  use  ;  but  if  the 
disease  has  been  long  in  a  chronic  state,  and  the  habit  of  body  be  not  irritable, 
relief  follows  its  application."     Op.  Cit.  p.  309. 

In  a  valuable  paper  by  Dr.  James  Forbes,  published  in  the  Medical  and 
Physical  Journal  for  October,  1822,  there  is  an  interesting  report  of  the  results 
bbtained  from  the  use  of  tar  vapor  in  one  of  the  military  hospitals.  It  is  there 
stated  that,  while  of  nineteen  cases  of  phthisis,  it  produced  bad  effects  in  elev- 
en, and  no  effect  in  eight;  of  thirty-two  cases  of  chronic  catarrh,  it  produced  a 
cure  in  eight,  an  improvement  in  six,  no  effect  in  eighteen,  and  bad  effects  in 
none.  This  may  perhaps  be  considered  as  a  fair  average  of  its  probable  effects 
in  this  disease. —  Transl. 

A  new  mode  of  treating  chronic  catarrh  has  lately  been  proposed  by  M.  Gan- 
nal,  viz.  the  inhalation  of  chlorine  gas.  When  used  with  the  requisite  caution, 
this  treatment  is  productive  of  none  of  the  inconveniences  that  might  be  ex- 
pected from  it  at  first  sight :  it  neither  excites  cough  nor  increases  dyspnoea,  nor 
gives  rise  to  any  pain  in  the  chest,  and  indeed  seems  to  act  merely  by  modify- 
ing, in  a  greater  or  less  degree,  the  characteristic  secretion  of  the  bronchial 
membrane,  which  gradually  disappears  under  its  use.  As  chlorine  thus  applied 
is  unquestionably  an  irritant  to  the  mucous  membrane,  it  probably  produces  its 
good  effects  by  substituting  one  inflammation  for  another.  The  following  is  the 
mode  of  administering  this  remedy  :  The  apparatus  may  be  either  a  Wolff's 
bottle  or  simply  a  wide-mouthed  bottle  having  its  cork  traversed  by  two  glass 
tubes  disposed  as  in  Wolff's  apparatus;  into  this,  a  small  portion  of  water  is 
poured  sufficient  for  the  immersion  of  the  extremity  of  one  of  the  tubes  to  the 
extent  of  nearly  an  inch  ;  and  when  this  water  is  raised  to  nearly  the  tempera- 
ture of  90°  a  few  drops  of  liquid  chlorine  is  added;  this  chlorine  is  vaporised 
along  with  the  warm  water,  and  is  inhaled  by  the  other  tube  along  with  the 
watery  vapor  and  the  air  which  flows  in  through  the  longer  tube.  The  flask 
must  be  at  least  half-pint  size,  otherwise  the  small  portion  of  water  which  it 
would  contain  would  cool  too  soon,  and  the  chlorine  gas  would  not  be  mixed 
with  a  sufficient  quantity  of  watery  vapor.  The  tubes  ought  to  be  from  four  to 
six  lines  wide:  as,  if  smaller,  respiration  would  be  fatiguing.  The  chlorine 
should  be  extremely  pure,  and  at  first  we  ought  not  to  use  more  than  six  drops 
at  a  time  ;  an  additional  drop  may  be  used  at  every  subsequent  trial  until  the 
dose  is  strong  enough  to  produce  some  uneasiness 'in  the  chest :  when  this  oc- 
curs, we  immediately  return  to  the  six-drop  dose,  and  ascend  progressively  as 
before.  It  is  quite  essential  that  the  application  be  repeated  at  least  six  or  eight 
times  daily.— (M.  L.)  n 

• 


CHRONIC    MUCOUS    CATARRH. 


87 


from  acquiring  over  the  system  the  force  of  an  habitual  discharge, 
when  it  is  ascertained  that  they  have  been  productive  of  no  ben- 
efit after  a  fair  trial.  When  the  dyspnoea  becomes  extreme,  nar- 
cotics, particularly  the  recently  prepared  powder  of  belladonna  or 
stramonium,  in  doses  of  half  a  grain  to  a  grain,  afford  most  relief. 
Their  administration  is  frequently  followed  by  the  speedy  but 
temporary  cessation  of  the  dyspnoea.*  If  the  expectoration  di- 
minishes or  is  altogether  suspended  by  the  conversion  of  the  dis- 
ease into  the  dry  catarrh,  a  circumstance  likely  to  happen  on  the 
occurrence  of  a  fresh  cold,  the  membrane  becomes  usually  more 
tumefied,  and  the  dyspnoea  is  consequently  increased.  In  these 
cases  an  emetic  is  of  the  most  service  ;  and  when  the  dyspnoea  is 
less  intense,  squill,  ipecacuan  and  kermes  given  in  small  doses. 
Should  this  state,  however,  continue  for  some  time,  we  must  have 
recourse  to  the  means  which  will  be  indicated  when  we  come  to 
speak  of  the  dry  catarrh.f 

*Ifat  this  period  of  relief  we  explore  the  respiration  by  the  stethoscope,  We 
find  it  the  same  as  during  the  paroxysm,  a  proof  that  the  benefit  obtained  con- 
sists simply  in  the  diminution  of  the  necessity  of  respiration. — Author. 

t  A  medicine  unnoticed  by  our  author,  but  which  has  been  pretty  extensively 
employed  in  this  country  of  late  years,  in  chronic  catarrh,  is  colchicum.  Like 
the  balsams,  it  is  a  very  uncertain  remedy,  and  like  them  is  inapplicable  if  not 
injurious  in  many  cases.  Like  them,  however,  it  is  also  occasionally  useful,  and 
ought  not  to  be  neglected  by  the  judicious  practitioner.  The  following  is  the 
account  given  of  it  by  Dr.  Hastings  :  "  It  allays  the  cough,  promotes  the  flow  of 
urine,  and  keeps  up  a  regular  alvine  discharge.  It  can  be  given  much  more  gen- 
erally than  squills,  because  it  does  not  produce  that  feverishness  which  results 
from  the  use  of  the  latter  remedy,  and  can  therefore  be  employed  where  there  is 
considerable  fever.  The  dose  generally  prescribed  is  twenty  drops  (of  the  tinc- 
ture) three  times  a  day.  In  some  cases  this  must  be  diminished  on  account  of 
its  action  on  the  bowels.  If  there  be  much  quickness  of  pulse  the  author  gene- 
rally adds  eight  or  ten  drops  of  the  tincture  of  foxglove,  from  which  combination 
the  cough  is  often  relieved  and  the  quickness  of  the  pulse  diminished."  Op. 
Cit.  p.  303. 

As  it  is  to  the  chronic  mucous  catarrh  that  the  greater  number  of  the  cases 
denominated  humoral  asthma,  and  also  the  disease  described  under  the  name  of 
habitual  asthma,  must  be  referred,  the  English  reader  will  consider  the  preceding 
observations  as  applicable  to  these  affections.  In  reference  to  the  cases  denomi- 
nated habitual  asthma,  the  scientific  and  highly  ingenious  mode  of  treating  these 
by  galvanism,  introduced  by  Dr.  Wilson  Philip,  deserves  some  notice  in  this 
place.  For  a  particular  account  of  this  practice  I  refer  the  reader  to  the  author's 
"Experimental  Inquiry  into  the  Laws  of  the  Vital  Functions."     2nd  Ed.  p.  331. 

If  the  advantages  of  this  mode  of  treatment  shall  be  found  as  striking  in  the 
hands  of  other  practitioners,  on  future  trials,  as  they  have  been  in  those  of  Dr. 
Philip,  it  must  be  considered  rather  discreditable  to  the  profession,  that  such 
trials  have  been  so  long  end  so  generally  delayed.  In  this  case,  as  in  that  of 
mediate  auscultation,  it  is  probable  that  the  trouble  requisite  for  the  application 
of  the  means,  is  the  principal  cause  of  their  not  being  applied.  Indolence  is  a 
potent  and  prevailing  advocate,  even  with  the  most  active.  We  readily  per- 
suade ourselves  that  what  is  very  troublesome  to  do,  may  be  left  undone,  with 
little  detriment  to  ourselves  or  others  ;  and  that  an  easy  substitute  is  an  ade- 
quate substitute.  If  the  mere  feeling  the  skin  could  convey  a  galvanic  shock, 
or  the  simple  listening  to  the  breathing  could  stand  in  place  of  mediate  auscul- 
tation, we  should,  I  suspect,  have  no  reason  to  complain  of  the  neglect  of 
these  two  important  measures,  in  practice.  I  wish,  in  the  present  case,  as  well 
as  others,  I  could  plead  less  guilty  to  the  charge  of  professional  indolence.    Sev- 


8S  PITUITOUS    CATARRH. 


Sect.  III. — Of  the  pituitous  culurrli. 

I  give  this  name  to  that  variety  of  catarrh  in  which  the  expec- 
toration is  colorless,  transparent,  ropy,  frothy  on  the  surface,  and 
underneath  like  white  of  egg  diluted  with  water.  It  has  been 
already  stated  that  this  kind  of  expectoration  commonly  appears 
at  the  onset  of  catarrh,  but  then  only  in  small  quantity ;  and  it 
sometimes  re-appears  towards  the  close  of  the  disease.  It  is  fre- 
quently intermixed  with  the  denser  sputa  of  the  chronic  mucous 
catarrh,  particularly  when  this  is  aggravated  into  an  acute  char- 
acter. It  also  occurs  occasionally  during  the  resolution  of  peri- 
pneumony,  and  in  the  oedema  of  tlie  lungs.  In  all  these  cases, 
this  species  of  expectoration  exists  only  temporarily,  for  a  few  days 
or  weeks  at  most ;  but  there  are  two  others  in  which  it  assumes 
a  very  slow  progress.  The  first  of  these  I  shall  denominate  the 
idiopathic  pituitous  catarrh  ;  the  second  co-exists  with  an  accu- 
mulation of  miliary  tubercles  in  the  lungs. 

Idiopathic  pituitous  catarrh.  The  anatomical  characters  of 
this  affection  are  a  middling  degree  of  swelling  and  a  slight  soften- 
ing of  the  mucous  membrane,  with  a  slight  appearance  of  redness 
here  and  there.  It  may,  therefore,  be  considered  as  occupying 
the  limits  between  the  serous  and  sanguineous  congestions,  and  as 
belonging  rather  to  the  former  than  the  latter. 

The  signs  of  this  affection  are  the  following  :■  the  expectoration 
is  as  above  described  ;  the  chest  sounds  well  on  percussion  ;  the 
sound  of  respiration  is  weaker  during  the  fits  of  coughing  than 
in  the  intervals,  but  is  seldom  altogether  suspended  in  certain 
points  of  the  chest ;  it  is  attended  by  a  sonorous  rhonchus,  flat 
or  sibilous,  imitating  the  chirping  of  birds,  the  note  of  a  violon- 
cello, or  the  cooing  of  the  wood-pigeon.  With  this  there  is  fre- 
quently intermixed  a  mucous  rhonchus,  but  this  conveys  the 
impression  of  being  produced  by  a  thinner  fluid  than  the  mucus 
of  the  common  catarrh.  In  the  intervals  of  the  attacks,  these 
various  rhonchi  exist,  Jaut  in  a  much  less  degree  ;  and  sometimes 
there  is  only  perceptible  a  very  slight  dull  whistling,  extending 
over  the  whole  bronchi,  unlike  the  partial  and  acute  sound  which 
constitutes  the  sibilous  rhonchus  properly  so  called.  (This  va- 
riety of  the  phenomenon  may  be  denominated  subsibilant  respi- 
ration.)     The    respiratory    sound    is    louder    than    during    the 


cral  years  since,  I  certainly  did  try  galvanism  in  a  few  cases  of  chronic  mucous 
catarrh,  in  the  persons  of  Cornish  miners ;  and  the  results,  as  far  as  Ihey  went, 
were  both  interesting  and  satisfactory.  In  these  trials,  which  were  only  repea- 
ted two  or  three  times,  the  breathing  was  temporarily  improved,  and  the  quantity 
of  mucus  in  the  bronchi  diminished  under  the  immediate  action  of  the  galvan- 
ism, as  was  proved  by  the  diminution  of  the  mucous  rhonchus  under  the  stetho- 
scope.—  Transl. 


PITU1T0US    CATARRH.  89 

paroxysms ;  sometimes  it  is  almost  puerile.  If  the  complaint 
has  been  of  long  standing,  and  has  already  occasioned  dilatation 
of  the  bronchi,  the  respiration  assumes  more  or  less  the  character 
of  the  variety  called  bronchial.  In  all  cases  it  varies  in  intensity 
in  different  points  of  the  chest,  and  these  points  vary  from  day 
to  day. 

This  disease  may  be  either  acute  or  chronic.  The  acute  pitui- 
tous  catarrh  constitutes  one  of  the  severest  species  of  the  suffo- 
cative catarrh.  It  is  characterized  by  an  extreme  oppression 
attended  by  a  copious  pituitous  expectoration.  It  sometimes  be- 
gins as  a  common  cold  ;  but  after  a  few  hours,  or  even  minutes, 
its  severe  character  is  soon  declared  by  the  violence  of  the  cough, 
the  intensity  of  the  dyspnoea  and  oppression,  the  lividity  of  the 
face,  marks  of  cerebral  congestion,  disordered  circulation,  and 
coldness  of  the  extremities.  In  children  it  is  sometime  mistaken 
for  croup.  I  had  occasion  to  know  a  case  of  this  kind  lately, 
where,  on  examining  the  body  after  death,  we  found  the  bronchi 
hardly  at  all  red,  but  nearly  filled  with  a  serous  fluid,  which  was 
somewhat  viscid  and  slightly  frothy.* 

The  stethoscopic  signs  of  this  affection  are  the  varieties  of 
rhonchus  already  noticed.  To  these  may  be  added  the  occasional 
presence  of  a  crepitous  rhonchus,  produced  by  a  certain  degree  of 
oedema  of  the  lungs  co-existing  with  a  serous  discharge.  The 
chest  sounds  well  on  percussion. 

These  attacks,  however  violent,  are  usually  transient.  In  cer- 
tain cases  they  are  recurrent.  A  remarkable  instance  of  this  is 
given  by  Bree,  of  a  woman  attacked  in  perfect  health  with  a 
paroxysm  of  the  kind  described,  passing  entirely  off  after  a  few 
hours  and  returning  in  the  same  manner,  and  with  extreme  vio- 
lence, after  an  interval  of  six  months.  In  the  second  attack  this 
patient  expectorated  four  pints  of  a  frothy  serum  slightly  tinged 
with  blood. 

Transient  pulmonary  fluxes  of  this  kind  may  be  regarded  as 
critical  and  as  one  of  the  modes  whereby  nature  seeks  to  get  rid 
of  some  morbific  cause,  which  may  or  may  not  be  perceptible  to 
us.      Accordingly,  we  occasionally  see  affections  of  the  kind  just 

*  Cases  like  these  have  repeatedly  occurred,  and  more  often  in  infancy  than 
at  any  other  stage  of  life.  I  lately  saw  a  case  of  measles  in  an  adult  terminate 
thus  unexpectedly  in  a  fatal  manner.  The  disease  had  proceeded  in  the  ordi- 
nary way  until  the  beginning  of  the  third  day  of  the  eruption  :  the  cough  was 
such  as  usually  attends  measles,  and  there  was  no  unusual  oppression,  when 
suddenly  came  on  a  frightful  dyspnoea,  which  in  twenty-seven  hours  was  fol- 
lowed by  death.  The  dyspnoea  from  the  beginning  was  attended  with  a  sibilous 
rhonchus,  which  could  be  heard  in  every  part  of  the  chest ;  it  was  very  distinct, 
and  in  some  places  was  mingled  with  a  slight  crepitation.  A  post-mortem 
examination  disclosed  no  other  lesion  than  a  bright  redness  of  the  lining  mem- 
brane of  the  bronchi,  and  a  frothy  liquid,  without  color,  and  ropy,  like  the 
white  of  an  egg. — Andral- 

12 


90  PITUITOUS    CATARRH. 

noticed,  and,  yet  more  frequently,  serous  vomitings  or  purgings, 
of  an  analogous  kind,  followed,  in  a  few  days  or  even  hours,  by 
the  dispersion  of  an  anasarca,  an  ascites,  or  hydrothorax. 

I  shall  notice  the  treatment  of  these  acute  pulmonary  fluxes 
when  I  come  to  notice  the  suffocative  catarrh. 

The  chronic  pituitous  catarrh  occurs  only  in  advanced  life, 
and  more  particularly  attacks  those  whose  constitutions  have 
been  debilitated  by  excesses,  or  by  sedentary  habits.  It  is  com- 
mon in  gouty  subjects  in  whom  the  gout  has  lost  its  regular  form, 
and  becomes  less  strongly  marked.  It  is  also  the  consequence  of 
frequently  repeated  attacks  of  the  acute  mucous  catarrh.  The 
chronic  variety  never  succeeds  the  acute  species  which  we 
have  just  described.  It  usually  comes  on  by  slow  degrees,  after 
repeated  attacks  of  the  acute  mucous  or  dry  catarrh.  When 
the  pituitous  discharge  is  once  fully  established,  it  becomes  fre- 
quently intermittent,  and  often  with  considerable  regularity. 
There  are  usually  two  paroxysms  of  cough  and  expectoration  in 
the  twenty-four  hours,  the  one  on  waking  from  sleep,  the  other 
in  the  evening :  but  sometimes  the  paroxysms  immediately  follow 
the  patient's  meals.  The  quantity  of  fluid  expectorated  is  al- 
ways very  great :  I  have  known  some  patients  discharge,  in  the 
course  of  one  or  two  hours,  from  two  to  three  pounds.* 

During  the  attack  there  is  always  dyspnoea,  which  either  dimin- 
ishes or  passes  off  with  it.  When  this  disease  has  existed  some 
time,  the  countenance  assumes  a  pale  bluish  tint,  and  the  body 
becomes  considerably  but  not  extremely  emaciated.  The  patient's 
constitution  becomes  more  lymphatic  ;  the  blood  grows  thinner, 
and  when  drawn  from  the  veins  exhibits  a  very  weak  coagulum. 
The  patient  nevertheless  continues  fit  for  many  avocations,  and 
can  be  considered  only  as  an  invalid.  In  this  state  the  complaint 
may  exist  a  great  many  years  ;  but  as  age  advances,  the  fits  be- 
come longer  and  more  frequent,  the  dyspnoea  becomes  habitual, 
and  the  disorder  then  acquires  the  name  of  asthma.  The  usual 
termination  of  it  is  by  the  supervention  of  oedema  of  the  lungs, 
and  finally  suffocation  from  inability  to  expectorate.^ 

*  It  has  been,  no  doubt,  the  suddenness  and  transient  nature  of  these  fluxes 
which  have  led  Junker  and  Salmuth  to  give  them  the  name  of  phlegmatorrhagies, 
which  has  been  since  applied  by  M.  Alard  to  similar  discharges  from  the  mucous 
membrane  of  the  stomach,  bowels,  uterus,  &c.  (Du  Siege  et  de  la  Nature  des 
Maladies,  torn.  ii.  Paris,  1821.)  I  would  propose  phlegmorrhagy  as  a  term  at 
once  more  easily  pronounced,  and  more  conformable  to  the  analogy  of  medical 
nomenclature. — Author. 

t  I  have  quoted  several  facts  in  my  Clinique  Medicate,  which  fully  confirm 
the  statements  of  Laennec  in  this  chapter.  There  is,  no  doubt,  a  variety  of 
asthma  caused  by  a  habitual  state  of  tumefaction  of  the  mucous  membrane  of 
the  smaller  bronchi.  Persons  attacked  by  it  suffer  more  or  less,  during  their 
lives,  from  shortness  of  breath :  they  are  almost  always  taking  cold,  and  by 
auscultation  exhibit  in  nearly  every  part  of  the  chest,  different  sorts  of  dry  or 
humid  rhonchi.     Some  of  these  individuals  have  hardly  any  cough  during  the 


PITUITOUS    CATARRH.  91 

It  is  singular  how  many  years  patients  will  survive  under  the 
immense  discharge  produced  by  this  disorder.  M.  Alard  men- 
tions some  interesting  examples  of  this  kind  ;  and  I  myself  am 
acquainted  with  two  old  gentlemen,  whose  cases  may  be  added 
to  the  number.  One  of  these,  who  is  upwards  of  seventy,  has  ex- 
pectorated during  the  last  ten  or  twelve  years,  in  two  daily  parox- 
ysms, about  four  pounds  of  a  colorless,  ropy,  and  frothy  fluid. 

day,  but  rise  in  the  morning  with  a  feeling  of  oppression  which  is  relieved  only  by 
the  expectoration  of  a  quantity  of  mucus,  commonly  transparent,  colorless  and 
ropy,  like  the  white  of  an  egg,  though  it  is  sometimes  opaque,  of  a  yellowish 
or  greenish  color,  and  puriform  in  appearance.  Such  persons,  however,  are  not 
commonly  regarded  as  invalids,  nor  do  they  consider  themselves  as  such.  But 
from  time  to  time*,  on  taking  cold,  their  respiration  becomes  obstructed,  and 
they  have  what  is  called  a  fit  of  asthma.  During  the  fit,  the  vesicular  "respira- 
tion cannot  be  heard,  and  its  place  is  occupied  by  a  coarse  or  sibilous  rhonchus. 
As  the  fit  goes  off,  the  rhonchus  changes  its  character,  and  becomes  gradually 
sub-crepitous  and  then  mucous.  In  some  individuals,  however,  the  dry  rhon- 
chus merely  diminishes  in  extent  and  intensity,  without  being  succeeded  by  the 
humid  one. 

The  morbid  state  of  the  bronchi  which  I  have  here  described  is  therefore  a 
continuous  disorder  with  exacerbations  at  intervals.  There  are  cases,  however, 
in  which  the  malady  is  truly  intermittent.  In  these,  the  habitual  respiration  is 
unobstructed — and  auscultation  shows  a  pure  and  deep  respiration  in  every 
part  of  the  lungs  ;  a  circumstance  which  distinguishes  these  cases  from  those  in 
which  dyspnoea  accompanies  emphysema  of  the  lungs.  But  from  time  to  time 
a  sudden  and  great  difficulty  of  breathing  arises  from  some  known  or  unknown 
cause,  and  is  attended  from  the  commencement  by  the  various  sorts  of  rhonchi 
above  enumerated  :  their  intensity  and  extent  point  out  in  the  clearest  manner 
the  progress  of  the  bronchial  secretion,  with  its  different  periods  of  increase 
and  diminution.  The  affection  terminates  in  a  space  of  time  varying  from  48 
hours  to  1.5  days,  when  the  function  of  respiration  becomes  perfectly  regular 
and  healthy.  Nevertheless,  as  these  attacks  are  renewed  and  at  shorter  inter; 
vals,  there  is  reason  to  fear  that  during  the  intervals  the  mucous  membrane  of 
the  bronchi  may  not  fully  relieve  itself,  but  remain  more  or  less  swollen,  and 
produce  finally  a'  habitual  dyspnoea  :  the  same  result  may  be  occasioned  by  age. 
The  recurrences  of  pulmonary  catarrh  instead  of  becoming  more  frequent,  may, 
on  the  contrary,  become  less  frequent,  and  disappear.  I  have  for  a  long  time 
attended  a  young  man  of  15  or  16  years,  who  from  his  earliest  infancy,  had 
constant  attacks  of  bronchial  catarrh  every  two  or  three  months.  The  frequency 
of  the  attacks  continued  the  same  up  to  the  age  of  twelve  :  the  least  exposure 
to  any  variation  of  temperature  brought  them  on  with  surprising  facility.  By 
my  advice,  he  was  carefully  secluded  the  whole  winter  in  a  room  kept  con- 
stantly in  a  moderate  and  uniform  temperature.  During  the  first  part  of  his 
confinement  he  had  several  violent  attacks  of  dyspnoea — afterwards  it  occurred 
more  seldom,  and  for  three  years  following  I  perceived  it  gradually  to  diminish 
in  frequency  and  intensity,  till  in  the  end  it  disappeared  altogether.  At  present 
more  than  a  year  has  passed  without  its  recurrence  ;  and  this  young  man  is 
strong  and  healthy,  without  any  sign  of  any  disease  in  the  chest.  In  cases 
similar  to  this,  my  practice  is  to  bleed  freely  in  the  beginning,  and  then  to  blis- 
ter the  chest  and  administer  purgative  medicine  enough  to  produce  seven  or 
eight  evacuations  in  twenty-four  hours  ;  towards  the  end  of  the  crisis  I  prescribe 
the  kermes  mineral  or  white  oxide  of  antimony.  Although  in  most  cases,  these 
attacks  of  dyspnoea  are  not  accompanied  by  any  immediate  danger,  they  may  some- 
times be  sufficiently  violent  to  occasion  death.  An  example  occurred  under  my  ob- 
servation the  present  year,  in  the  person  of  a  man  of  55  or  60,  who  has  been 
long  subject  to  the  complaint.  On  dissection,  the  body  exhibited  no  appearance 
of  disease  in  the  heart  or  large  vessels,  nor  of  emphysema  of  the  lungs.  The 
mucous  membrane  of  the  bronchi  only  was  very  red,  and  covered  in  many, 
places  with  a  tenacious  and  viscid  mucus. — Andral. 


92  PITUITOUS    CATARRH. 

The  other  brings  up  every  morning,  by  gentle  spontaneous  vom- 
itings, repeated  at  short  intervals  during  several  hours,  from  three 
to  six  pounds  of  a  liquid  exactly  like  white  of  egg  mixed  with  a 
third  part  of  water.  This  gentleman  is  upwards  of  sixty,  enjoys 
tolerable  health,  and  walks  several  hours  every  day.  Some  pa- 
tients, however,  die  of  exhaustion  within  a  much  shorter  period, 
and  from  a  much  smaller  discharge.  Two  cases  of  this  kind  are 
given  by  M.  Andral : — the  one,  an  old  man,  carried  off  after  five 
months,  by  the  daily' expectoration  of  about  two  pints  of  a  serous 
fluid  ; — and  the  other,  a  person  of  forty-five  years  of  age,  who  died 
after  bringing  up  three  pints  of  the  same  kind  every  day,  during 
three  successive  years.  In  neither  of  these  cases  was  there  found 
any  other  cause  of  death  ;  and  in  the  one  last  mentioned,  the  mu- 
cous membrane  of  the  bronchi  was  found  extremely  pale  :*  so  true 
it  is,  that  besides  the  light,  no  doubt  very  great,  thrown  by  mor- 
bid anatomy  on  the  causes  of  these  diseases,  we  must,  in  certain 
cases,  look  elsewhere  for  information. 

It  is  rare  that  we  meet  with  idiopathic  cases  of  this  disorder  so 
well  marked  as  those  just  noticed  ;  but  it  often  exists  in  a  high  degree 
as  a  consequence  of  the  simultaneous  development  and  persistence 
of  a  great  number  of  miliary  tubercles  in  the  lungs.  These  pi- 
tuitous  discharges  were  indeed  considered  by  Bayle  as  the  path- 
ognomonic sign  of  this  variety  of  phthisis.f  The  symptomatic 
pituitous  discharges  are  marked  by  less  regular  fits  of  coughing, 
and  they  present,  moreover,  particular  signs,  depending  on  their 
organic  cause,  which  will  be  noticed  when  we  come  to  treat  of 
phthisis. 

Treatment.  The  idiopathic  pituitous  catarrh,  when  it  has  be- 
come habitual,  may  be  considered  as  little,  if  at  all,  under  the  in- 
fluence of  medicine.  On  this  account,  when  the  mucous  or  dry 
catarrhs  are  complicated  with  this  affection,  we  must  endeavor  to 
remove  all  traces  of  these.  The  means  recommended  against  the 
chronic  mucous  catarrh,  particularly  emetics,  are  often  beneficial 
in  this  case  ;  the  balsams  are  less  so,  and  ought  not  to  be  employ- 
ed, unless  the  disease  has  become  entirely  chronic.  Blisters  ap- 
plied first  on  the  chest,  and  subsequently  on  the  extremities,  are 
of  more  use  here  than  in  the  mucous  catarrh.  The  same  is  true 
of  opium  given  in  small  doses  frequently  repeated.^ 

*  Op.  Cit.  Obs.  xiv.  and  xvi.  t  Reeherchcs  sur  la  Phthisic. 

t  The  chronic  pituitous  catarrh  from  its  obstinacy  seems  to  demand  more  than 
any  of  the  other  kinds,  a  topical  treatment ;  and  it  is  in  it  that  the  chlorine  "as 
would  seem  to  promise  most  effectual  relief.  I  have  found  great  benefit  from  it 
in  one  case. — (M.  L.) 


SUFFOCATIVE    CATARRH.  93 


Sect.  IV.     Of  the  suffocative  catarrh. 

This  term  is  commonly  applied  to  those  cases  of  chronic  mucous 
catarrh  of  long  standing,  very  frequent  in  old  persons,  in  which 
death  supervenes  from  the  superabundant  accumulation  of  mucus 
in  the  bronchi.  Considered  in  this  point  of  view,  it  is  rather  an 
accident  which  may  occur  in  several  species  of  catarrh*  than  a  dis- 
tinct species  in  itself.  Its  anatomical  characters  vary  somewhat 
according  to  its  causes ;  but  in  every  case  the  bronchi  are  in  a 
great  measure  filled  with  a  mucous  or  pituitous  secretion. 

The  signs  of  this  affection  are  a  laryngeal  and  tracheal  rhon- 
chus  extremely  strong,  perceptible  by  the  naked  ear  at  the  dis- 
tance of  several  feet.  The  respiration  is  frequent,  and  the  mo- 
tions of  the  chest  more  extensive,  and  more  apparent  than  in  the 
sound  state,-  except  at  the  approach  of  death.  The  stethoscope 
detects  over  the  whole  chest  a  mucous  rhonchus,  composed  of  large 
and  small  bubbles.  If  there  is  cough,  it  is  attended  by  a  moist 
sibilous  rhonchus  ;  but  most  commonly  there  is  no  cough  ;  and 
its  absence,  as  well  as  the  circumstances  under  which  the  disease 
usually  occurs,  would  seem  to  show  that  there  is  paralysis  of  some 
of  the  powers,  which,  in  the  natural  state,  produce  the  excretion 
of  the  pulmonary  mucus.  This  loss  of  power  appears  to  me  to  be 
most  probably  seated  in  the  bronchi,  or  the  pulmonary  texture  it- 
self, since,  as  we  have  already  said,  the  action  of  the  muscles  of 
inspiration  is  rather  increased  than  diminished,  at  least  in  the  be- 
ginning of  the  attack.  Percussion  elicits  a  good  sound  over  the 
whole  chest,  until  on  the  approach  of  death,  when  the  sound  is 
found  to  be  lessened  towards  the  roots  or  base  of  the  lungs,  owing 
to  the  mechanical  congestion  of  fluids,  in  these  parts.  It  is  espe- 
cially in  this  disease,  that  the  motion  of  the  mucus  in  the  bronchi 
may  frequently  be  perceived  by  applying  the  hand  to  the  chest. 

There  are  four  cases  in  which  catarrh  may  become  suffoca- 
tive.— 1.  in  old  persons  ; — 2.  in  persons  affected  with  cedema  of 
the  lungs; — 3.  in  the  dying  ; — 4.  the  acute  catarrh  may  some- 
times assume  this  character  even  in  adults  and  children. 

1.  In  old  persons.  This  accident,  which  is  almost  always  mor- 
tal, occurs  principally  in  winter,  and  in  consequence  of  the  super- 
vention of  an  acute  catarrh  to  a  chronic  mucous  catarrh  or  phleg- 
morrhagy.  If  of  any  continuance,  cedema  of  the  lungs  supervenes 
and  hastens  the  fatal  termination. 

2.  With  aidema  of  the  lungs.  (Edema  of  the  lungs  is  almost 
always  accompanied  by  a  phlegmorrhagy  which  may  readily  be- 
come suffocative,  from  the  accumulation  of  fluid  in  the  bronchi:, 
especially  in  weak  and  old  subjects. 

3.  In  dying  persons.     The  last  agony  in  almost  all  diseases,  is 


94  SUFFOCATIVE    CATARRH. 

accompanied  by  a  copious  tracheal  rhonchus,  and  consequently 
a  real  suffocative  catarrh,  except  in  those  cases  wherein  the  rhon- 
chus is  owing  to  the  presence  of  blood  in  the  bronchi.  (Edema, 
and  yet  more  commonly  a  sero-sanguineous  congestion  of  the 
pulmonary  texture,  accompanies  the  flow  of  fluid  into  the  bron- 
chi ;  and  it  is  to  this  circumstance  that  the  infiltration  of  the 
posterior  parts  of  the  lungs,  observable  in  almost  all  dead  bodies, 
is  to  be  attributed. 

4.  Acute  suffocative  catarrh  of  adults  and  children.  This 
variety  does  not  appear  to  me  to  have  hitherto  sufficiently  en- 
gaged the  attention  of  physicians.  It  is  very  rare  in  adults.  In 
young  children  it  is  more  common,  and  is  often  in  them  con- 
founded with  croup.  It  is  recognised  by  the  tracheal  rhonchus 
perceptible  by  the  naked  ear,  and  by  the  imminent  suffocation, 
and  frequent  lividity  of  the  face.  The  stethoscope  detects,  over 
the  whole  chest,  a  loud  mucous  (and  very  liquid)  rhonchus,  and 
a  very  frequent  and  usually  irregular  action  of  the  heart. 
This  disease  is  an  acute  catarrh  affecting  the  whole,  or  a  very 
large  portion  of  the  mucous  membrane  of  the  lungs.  Its  dura- 
tion is  from  twenty-four  to  forty-eight  hours,  or  at  most,  some 
days.  At  the  end  of  this  time,  either  the  patient  dies,  or  expec- 
toration commences  and  puts  an  end  to  the  suffocation,  and  the 
disorder  then  follows  the  progress  of  a  simple  acute  catarrh. 
While  the  suffocation  lasts,  there  is  little  cough,  and  the  expec- 
toration, if  any,  is  altogether  pituitous  or  fluid :  it  retains  this 
character  for  some  days  at  least,  and  then  becomes  more  abun- 
dant ;  but  recovery  sometimes  takes  place  without  its  ever  be- 
coming properly  mucous ;  in  which  case,  the  disease  is  only  a 
variety  of  the  acute  bronchial  phlegmorrhagy  or  pituitous  ca- 
tarrh. When,  on  the'  other  hand,  the  expectoration  becomes 
mucous,  the  disease  is  simply  an  ordinary  acute  catarrh,  in  which 
the  suffocative  character  of  the  invasion  is  caused  by  the  extent  of 
tumefaction  of  the  bronchial  membrane,  and  by  the  great  quanti- 
ty of  fluid  secreted  at  once. 

Treatment.  I  shall  notice  in  another  place  the  catarrh  which 
accompanies  oedema  of  the  lungs  ;  and  I  need  not  here  stop  to 
say  any  thing  respecting  that  of  the  dying.  The  suffocative 
catarrh  of  old  persons  may  sometimes,  though  rarely,  be  cured 
by  those  means  which  prove  successful  in  the  acute  affection  of 
adults  and  children.  The  first  and  most  efficacious  of  these 
means  are  emetics,  repeated  daily,  if  the  first  has  procured  only 
slight  relief,  and  without  increase  of  the  expectoration.  Lar<*e 
blisters  applied  at  the  same  time  to  the  thigh,  prove  often  salutary 
derivatives.  I  prefer  this  situation  to  the  chest,  because  I  have 
several  times  had  occasion  to  observe,  particularly  in  old  persons, 
that  when  applied  to  the  latter,  they  rather   increased   the  suf- 


SUFFOCATIVE    CATARRH.  95 

focation.  Besides  the  danger  common  to  all  derivatives  applied 
near  the  part  affected,  of  augmenting  in  place  of  lessening  the 
congestion,  the  blister  applied  to  the  chest  has  the  additional 
disadvantage  of  impeding  the  thoracic  movements,  at  the  very 
time  when  the  full  extent  of  inspiration  is  requisite  to  prevent 
suffocation.  I  have  never  found  bleeding  indicated  in  the  suffo- 
cative catarrhs  of  children,  or  in  the  few  cases  of  the  same  affec- 
tion which  I  have  met  with  in  adults.  I  am  of  opinion,  however, 
that  it  may  sometimes  be  advantageous  in  individuals  of  a  san- 
guine constitution.  The  loss  of  blood  favors  absorption,  and 
diminishes,  at  least  for  a  time,  the  greater  number  of  the  secre- 
tions and  exhalations. .  In  this  respect  it  may  be  useful  in  such 
cases ;  but  if  carried  too  far  there  is  reason  to  fear  that  it  may 
so  debilitate  the  patient  as  not  only  to  check  expectoration,  but 
even  so  much  weaken  the  muscles  of  inspiration^  as  to  inca- 
pacitate them  for  the  increased  labor  which  they  nave  to  per- 
form.* We  must  likewise  endeavor  to  diminish  the  necessity 
of  respiration  by  administering  paregorics,  among  which  I  give 
the  preference  to  the  powdered  root  of  belladonna,  in  the 
dose  of  half  a  grain  or  a  grain,  repeated  at  such  intervals  as 
the  severity  of  the  suffocation  and  the  patient's  strength  seem  to 
require. 

*  This  is  evidently  written  under  the  influence  of  strong  prejudice.  It  cannot 
be  questioned  that  bloodletting,  and  particularly  local  bloodletting,  is  indicated 
in  the  true  soffbcative  catarrh,  and  the  relief  afforded  by  it  is  so  speedy  and  com- 
plete, that  it  is  very  unlikely  that  it  should  be  carried  too  far.  The  dread  of 
weakening  the  patient  so  as  to  check  tiie  expectoration,  is  quite  visionary,  since 
we  know  that  the  violence  of  the  dyspncea  arises  much  more  from  the  tumefac- 
tion of  the  bronchial  membrane,  than  from  the  amount  of  the  bronchial  secretion. 
Leeches,  in  large  numbers,  or  still  better,  cupping  on  thy  chest,  with  counter- 
irritation  by  means  of  blisters,  and  sinapisms  on  the  lower  extremities,  will  al- 
ways be  found  the  most  effectual  method  of  treating  the  suffocative  catarrh  of 
children  and  adults. — (M.  L.)\ 

In  the  justness  of  the  above  remark  I  entirely  concur. —  Transl. 

t  No  doubt  bleeding  is  of  great  use  in  a  large  number  of  cases  of  these  bron- 
chial affections,  called  by  Laenncc  on  occount  of  their  common  and  predomina- 
ting  symptoms,  suffocative  catarrhs.  But  I  think  with  him,  that  care  should  be 
taken  not  to  abuse  this  remedy,  and  that  it  ought  not  to  be  employed  in  all 
cases.  It  is  at  least  an  important  question  how  far  bleeding  will  diminish,  with 
a  constant  and  uniform  efficacy,  the  engorgement  of  the  mucous  membrane  of 
the  bronchi  and  check  its  abundant  secretion.  Is  this  engorgement  always  of 
the  same  nature?  Is  the  cause  of  this  hyperemia  always  the  same?  Whatever 
theory  be  adopted  on  these  points,  observation  seems  to  prove  that  in  many 
cases  where  a  patient,  cither  child,  adult,  or  aged,  exhibits  on  a  sudden  the 
symptoms  of  suffocative  catarrh — understanding  the  term  in  either  of  the  signi- 
fications attached  to  it  by  Laennec — bleeding,  instead  of  reducing  the  suffoca- 
tion, augments  it ;  and  that  immediately  after  this  operation,  the  rhonchi  often 
become  louder,  and  extend  from  the  bronchi  to  the  trachea. 

I  submit  these  remarks  to  the  experience  of  practitioners,  in  the  belief  that 
the  opinion  of  Laennec  will  be  confirmed  by  such  a  test.  No,  it  is  not  merely 
because  a  part  is  red  and  tumefied,  or  its  secretion's  are  altered,  that  bleeding  is 
indicated  :  for  these  morbid  appearances  are  not  always  the  result  of  the  same 
inflammatory  process,  and  in  some  instances  bark  is  a  better  remedy  than  bleed- 
ing.— Andral. 


96  DRY    CATARRH. 

In  two  cases  I  employed  no  other  means  than  the  emetic  tar- 
tar, given  in  large  doses,  as  will  hereafter  be  particularly  de- 
scribed in  the  chapter  on  pneumonia.  In  one  case  the  catarrh 
was  complicated  with  cedema  of  the  lungs.  The  other  was  a 
woman  twenty-four  years  ofage,  of  a  robust  constitution  ;  this 
patient,  although  apparently  almost  expiring  when  she  came  into 
the  hospital,  was  out  of  danger  in  twelve  hours.  The  other  pa- 
tient also  recovered,  but  more  slowly.* 

Sect.  V.f  Of  the  dry  catarrh  and  the  latent  catarrh. 

The  expression  dry  catarrh  involves  .a  contradiction  if  we 
look  to  etymology,  since  the  word  catarrh  denotes  a  flux  or  dis- 
charge ;  but  as  this  phrase  has  been  used  by  the  moderns,  I  shall 
employ  it  in  this   place  to  designate  those   inflammations  of  the 

*  I  am  of  opinion  that  our  author, in  the  four  preceding  sections  has  conveyed 
to  the  reader  a  general  impression  of  less  severity  in  the  diseases  treated  of,  than 
the  inflammation  of  the  mucous    membrane  of  the  bronchi  often  exhibits.     And 
ifthisbeso,    I  suspect  that  the    cause  will  be  found  in  his    determination  to  de- 
scribe the  affections  under  the  name  catarrh  and  not  bronchitis.     I  think  the  im- 
pression  would    have  been    more  clear    and  forcible,  although    the    delineation 
might  not  have  been  at  all  more  accurate,  had    bronchitis  been    taken  as  the  ge- 
nus, and  the  varieties  of  catarrh  above  described  given  as  species  of  this.     It  is 
no  doubt   true,  as   remarked  by  the    author,    that    catarrh   frequently  forms    the 
shade  between  inflammation  and  congestion,  and  that  in  certain  cases  of  catarrh 
it  is  very  doubtful  if  there  is  really  any  inflammation  of  the  mucous  membrane. 
But  it  is  equally  true,    that  very  unequivocal    and  violent  inflammations  of  this 
membrane  do  exist,  exclusively  of  those  of  the  croupy  or  plastic  kind.     And  the 
history  of  the  disease    delivered  by  our^iuthor,   seems  to  me  defective    in  not 
containing  a  distinct  and   separate  account  of  this  severe  and   highly  inflamma- 
tory variety.     The  attention  of  the  reader  seems  too  much  directed   to  the  kind 
of  secretion,  and  too  little  to  the  actual  disease  of  the   membrane,  the   cause  of 
this.     These  remarks 'apply  most  forcibly  to  the  affections  described  in  the  last 
section  under  the  name  of  suffocative  catarrh,  which  can  only   be  considered  as 
an    accidental  modification    of  the  kinds  previously  described,  and  ought  not, 
therefore,  to  have  been  noticed  as  constituting  a  distinct  species.     This,  indeed, 
is  admitted  by  the  author  himself  in  respect  to  all  the   varieties  included  under 
this  title,  except  the  last,  the   acute  suffocative  catarrh  of  adults  and  children. 
This  variety  of  bronchitis  has  been   noticed  by  many  writers   under    different 
names.     For  a  very  complete  history  of  all  the   varieties  of  bronchitis,  and  a 
pretty  complete   and  accurate   account  of  the   opinions  of  preceding  authors,  I 
would  refer  to  the  work  of  Dr.  Hastings  formerly  quoted,  to  Dr.  Badham's  Es- 
say  on   Bronchitis,  and   to  the  second  volume  of  Andral's   Clinique   Medicale. 
The  disease  described  by  Dr.  Millar,  ("  Observations  on  the  Asthma  and  on  the 
Hooping  Cough,  by    John  Millar,   M.   D.  1769,")  under    the   name  of  Asthma, 
and   which  occurred  as   an  epidemic  among  children   in  the  border  counties  of 
England  and  Scotland  in  the  year  1755,  was  evidently  that  species  of  bronchitis, 
described  by  our  author  as  the  acute   suffocative  catarrh.     Several  well   marked 
and  well   described  cases  of  the  suffocative   catarrh,  with  the   appearances  on 
dissection,    are  detailed   by  the   late    Mr.   Chevalier,  in-the    London   Med.  and 
Phys.  Journal,  vol.  vii.  and  many  valuable   observations  of   a  similar  kind  are 
scattered  through  the   various  periodical   journals  and   transactions  published  in 
this  country.     See  also   two  short  but  excellent  papers  by  Dr.  Williams   in  the 
Cyclopaedia  of  Practical  Medicine,  viz.  the  articles  Bronchitis  and  Catarrh. 
—  Transl. 

t  In  this  section  I  have  included  two  of  the  original.—  Transl. 


DRY    CATARRH.  97 

bronchi  which  are  attended  with  little  or  no  expectoration.  This 
affection  is  extremely  common  in  the  chronic  slate.  In  the  acute 
state  it  exists  at  the  commencement  and  also  at  the  close  of  a 
common  cold ;  but  in  this  last  case,  it  is  accompanied  by  a  pitui- 
tous  catarrh,  which  appears  to  have  its  seat  in  a  different  part  of 
the  mucous  membrane.  It  frequently  exists,  also,  in  an  entirely 
latent  state,  in  continued  fevers. 

The  chronic  dry  catarrh  is  most  usually  an  idiopathic  affection. 
It  is  frequent  in  gouty  and  hypochondriacal  subjects,  in  persons 
affected  with  cutaneous  eruptions,  and  in  those  whose  constitu- 
tions are  broken  down  by  excesses  of  any  kind.  It  frequently 
exists  in  a  slight  degree  in  individuals  who  are  otherwise  in  very 
good  health.  Almost  all  the  inhabitants  of  cold  sea  coasts  and 
damp  vallies,  are  perpetually  attacked  with  it  in  some  degree  or 
other ;  and  even  in  the  driest  parts  of  France,  in  one  half  at 
least  of  persons  arrived  at  adult  age ,  and  who  are  in  other  re- 
spects in  perfectly  good  health,  the  stethoscope  detects 'the  traces 
of  a  slight  habitual  thickening  or  congestion,  in  some  part  or 
other  of  the  mucous  membrane  of  the  lungs. 

The  anatomical  characters  of  this  affection  are — swelling,  to- 
gether with  an  obscure  redness,  or  violet  hue,  of  the  mucous 
membrane.  This  swelling  is  particularly  remarkable  in  the 
smaller  branches,  which  are  indeed  sometimes  almost  completely 
obstructed  by  it.  When  the  swelling  is  less,  these  branches  are 
frequently  blocked  up  by  a  very  glutinous  kind  of  matter,  of  the 
consistence  of  pitch,  or  somewhat  firmer,  disposed  in  globules 
of  the  size  of  hemp  or  millet  seed.  These  globules,  which  are 
always  free  from  air,  are  semi-transparent  and  of  a  pearl-grey 
color ;  which  color  is  no  doubt  owing  to  an  intermixture  of  a 
small  portion  of  black  pulmonary  matter,  as  this  occasionally 
shows  itself  more  conspicuously  in  them  under  the  form  of  small 
black  points.  This  matter,  which  many  persons,  who  do  not 
consider  themselves  as  having  a  cold,  expectorate  in  small  quan- 
tities every  morning,  has  been  called  by  Fourcroy  bronchial 
mucus.  I  shall  denominate  it  pearly  expectoration  (sputa  mar- 
garitacea)  to  distinguish  it  from  the  pituitous  and  mucous  kinds 
already  described.  Sometimes  a  portion  of  one  of  the  larger 
bronchi  exhibits  over  a  space  of  only  a  few  lines  in  extent,  a 
swelling  of  its  internal  membrane  sufficient  to  obstruct  almost 
entirely  the  passage  of  the  air,  although  in  smaller  branches  of 
the  same  trunk  it  is  much  less  tumefied.  Andral  has  published' 
two  cases  of  this  variety  of  the  dry  catarrh.*  It  is,  howe/er, 
much  more  common,  as  I  have  already  stated,  to  find  the  mem- 
brane more  swollen  in  the  smaller  branches.     The  dry  catarrh  is 

Op.  Cit.  ubs.  ii.  and  iii. 

13. 


<)S  DRY    CATARRH. 

usually  the  more  extensive  the  longer  it  lias  lasted ;  although 
even  in  young  children  we  occasionally  find  the  whole  mucous 
membrane  affected.  When  universal,  or  when  only  very  exten- 
sive, it  always  gives  rise  to  emphysema  of  the  lungs. 

The  pathognomonic  signs  of  this  affection  are — a  perfect  reson- 
ance of  the  chest,  and  a  complete  or  nearly  complete  want  of  the 
natural  sound  of  respiration  in  the  parts  actually  affected.  These 
parts  change  frequently,  particularly  when  the  disease  is  very 
general ;  so  that  those  which  at  the  first  exploration  gave  no 
respiratory  sound,  may,  after  a  few  hours,  give  it  more  distinctly 
than  any  other,  and  vice  versa.  These  variations  are  accounted 
for  by  the  varying  states  of  congestion  in  the  mucous  membrane, 
and  by  the  varying  secretion  and  expectoration  of  the  pearly 
sputa.*  If  the  obstruction  of  the  smaller  bronchi  is  not  very 
great,  the  respiration  is  still  perceptible,  but  in  a  much  feebler 
degree  than  might  be  expected  from  the  resonance  of  the  chest. 
Over  the  parts  affected,  we  also  distinguish  a  slight  sibilous 
rhonchus,  and  more  rarely,  and  only  during  a  deep  inspiration, 
a  clicking  like  that  of  a  small  valve,  occasioned,  no  doubt,  by 
the  displacement  of  the  pearly  sputa.  The  respiration  continues 
natural  in  the  parts  of  the  lungs  which  remain  sound,  and  rarely 
becomes  puerile  as  in  pleurisy  or  peripneumony :  this  last  fact  is 
explained  by  the  very  slow  progress  of  the  dry  catarrh,  which  has 
gradually  accustomed  the  patients  to  an  imperfect  degree  of  respi- 
ration, and  prevented  the  necessity  of  the  sound  portions  of  the 
organ  supplying  the  deficiencies  of  the  diseased,  by  a  preternat- 
ural energy  of  action.     As  the  sound  of  the  pulmonary  respira- 

*  Nothing  certainly  is  more  remarkable  than  the  variations  observable  from 
day  to  day  in  the  intensity  of  the  respiratory  sound  in  some  who  labor  under 
the  malady  here  described  by  our  author.  To-day  the  sound  is  not  to  be  heard; 
to-morrow  it  is  powerful.  These  variations  which  correspond  to  the  different 
degrees  of  engorgement  of  the  mucous  membrane  of  the  bronchi,  may  serve 
to  distinguish  that  species  of  asthma  caused  simply  by  this  engorgement,  from 
that  which  arises  from  emphysema  of  the  lungs.  In  these  last  cases,  the  feeble- 
ness or  even  the  absence  of  tin?  respiratory  murmur  suffers  no  such  variation; 
it  is  always  uniform  or  increases  gradually. 

A  considerable  degree  of  engorgement  of  the  mucous  membrane  of  the 
larynx,  may  obstruct  the  entrance  of  the  air  into  this  organ  in  such  a  manner 
that  no  sound  can  be  heard  throughout  the  whole  extent  of  the  lungs,  except  a 
very  feeble  vesicular  murmur;  and  in  some  points  not  even  this.  If  at  this 
time  the  chest  resounds  very  loud  on  percussion,  as  in  lean  persons,  a  suspicion 
may  arise  of  the  existence  of  an  emphysema  of  the  lungs  :  yet  nothing  of  the 
sort  exists. 

This  was  the  case  with  a  female  who  was  lately  under  my  care  with  chronic, 
laryngitis.  In  this  patient  the  air  passed  with  great  difficulty  through  the  glottis, 
and  hanlly  any  murmur  of  respiration  could  be  distinguished  in  the  lungs. 
Suffocation  became  so  rapidly  alarming  from  day  to  day,  that  I  decided  upon 
tracheotomy:  hardly  was  the  operation  finished,  when  the  dyspnoea  diminished ; 
the  next  day  or  two  a  perceptible  improvement  took  place,  and  the  respiratory 
murmur,  so  feeble  before  the  operation  as  to  lead  me  to  suspect  emphysema  of 
the  lungs,  resumed  everywhere  its  natural  degree  of  intensity.  This  case  so 
interesting  in  many  points,  I  shall  publish  in  ail  its  details.— Aniral 


DRY    CATARRH.  99 

tion,  properly  so  called,  is  nearly  wanting  in  this  affection,^  might 
naturally  be  expected  that  the  bronchial  respiration  would  be  oc- 
casionally perceptible  in  it.  This,  however,  is  never  the  case,  ac- 
cording to  my  experience  ;  and  a  lull  consideration  of  all  the  cir- 
cumstances appears  to  render  this  occurrence  very  improbable  if 
not  impossible.  The  state  of  parts  in  this  disease  is  extremely  un- 
favorable for  perceiving  every  kind  of  sound  originating  in  the  lungs. 
In  the  first  place,  the  greater  number  of  the  air  cells  are  habitual- 
ly distended  by  the  air,  so  that  the  pulmonary  substance  is  ren- 
dered less  dense,  and  thereby  less  fitted  for  the  transmission  of 
sound  ;  and  in  the  second  place,  many  of  the  bronchial  tubes,  even 
those  of  considerable  size,  are  habitually  obstructed  either  by  the 
swelling  of  their  inner  membrane,  or  by  the  glutinous  matter  se- 
creted by  it. 

The  habitual  dry  catarrh  is  sometimes,  though  rarely,  compli- 
cated with  the  mucous  or  pituitous  catarrh,  acute  or  chronic.  In 
this  case  we  find  the  signs  of  each  affection  in  different  portions 
of  the  lungs  ;  while  the  re-union  of  the  three  varieties  is  further 
proved  by  the  simultaneous  expectoration  of  their  characteristic 
sputa — the  pituitous,  the  mucous,  and  the  pearly. 

Symptoms  and  progress.  This  disease  when  existing  in  a 
middling  degree,  frequently  remains  altogether  latent  for  a  long 
course  of  years, — the  subjects  of  it  being  no  further  conscious  of 
its  presence  than  by  observing  that  they  are  shorter  breathed  than 
others,  when  they  ascend  a  height  or  attempt  to  run.  When  the 
bronchial  tumefaction  becomes  more  extended,  dyspnoea  is  then 
experienced,  even  in  a  state  of  quietude,  and  particularly  after 
meals ;  and  this  state  of  oppression  is  referred  by  some  patients 
to  one  side  only,  and  sometimes  to  the  side  least  affected.  After 
a  time  the  dyspnoea  comes  on  in  fits  which  last  usually  several 
days,  and  are  so  severe  as  to  merit  and  obtain  the  name  of  asthma. 
Towards  the  termination  of  these  attacks,  a  cough  comes  on  and 
the  oppression  becomes  less  ;  and  after  the  cough  has  continued 
a  few  days  the  dyspnoea  is  still  further  relieved  by  the  expectora- 
tion of  some  of  the  pearly  sputa  intermixed  with  phlegm.  In  the 
slighter  cases,  these  sputa  lose  their  usual  consistence  and  globu- 
lar form,  and  Become  more  copious,  and  feebly  opaline  from  an 
intimate  intermixture  of  a  small  quantity  of  an  opaque  yellowish 
or  white  mucus.  At  other  times  they  are  vitriform,  and  nearly 
of  the  consistence  of  the  vitreous  humor  of  the  eye, — constitu- 
ting, no  doubt,  the  glassy  pituita  of  the  ancients.  An  expecto- 
ration of  this  kind  is  habitual  with  many  persons  affected  with  a 
slight  degree  of  the  dry  catarrh  ;  and  as  long  as  it  continues  they 
are  never  liable  to  attacks  of  asthma.  Frequently  this  expectora- 
tion is  in  such  small  quantity  that  the  patients  are  themselves  uncon- 
scious cither  of  it  or  the  cough;  in  some  persons  there  is  in  fact 


100  DRY    CATARRH. 

neither  the  one  nor  the  other ;  and  in  many  there  is  merely  a  slight 
cough  perfectly  dry,  and  perceptible  only  once  daily,  or  once  in 
two  or  three  days.  Coughs  of  this  kind,  when  the  dry  catarrh  of 
which  they  are  the  symptom  has  come  on  slowly  and  without 
being  preceded  by  an  acute  affection,  are  usually  denominated 
nervous.  Too  frequently  indeed  they  are  considered  sympathet- 
ic, and  the  cause  of  them  is  sought  for  in  some  real  or  supposed 
affection  of  the  stomach,  liver,  kidneys,  or  uterus.  Hence  the 
coughs  called  gastric,  hepatic,  hysteric,  fyc. ;  all  of  which  are,  in 
fact,  examples  of  the  co-existence  of  the  dry  catarrh  with  some 
affection  of  the  particular  organs  indicated.  Very  commonly  the 
cough  ceases  entirely  during  summer,  and  the  oppression  be- 
comes less  ;  no  doubt  because  the  increase  of  the  cutaneous  tran- 
spiration diminishes  the  gorged  state  of  the  bronchi  and  the  secre- 
tion of  the  pearly  sptsta. 

When  a  person  subject  to  an  habitual  dry  catarrh  is  attacked 
with  an  acute  catarrh,  this  rarely  goes  through  its  regular  course, 
so  as  to  give  rise  to  the  copious  mucous  expectoration  characteris- 
tic of  it.  On  the  contrary,  it  seems  never  to  get  beyond  the  first 
stage  ;  but  after  a  few  days  the  cough  becomes  more  frequent, 
and  is  attended  by  a  slight  pituitous  expectoration,  and  a  greater 
discharge  than  usual  of  pearly  sputa  of  a  thinner  quality.  Some- 
times, indeed,  their  consistence  is  so  much  diminished,  that  they 
lose  their  rounded  form  and  become  diffluent ;  and  in  this  state 
they  exhibit  a  compound  of  the  pearly  and  glassy  sputa,  and  the 
yellow  and  viscid  mucus  of  common  catarrh,  rendered  opaque  and 
greyish  by  the  intermixture  of  much  black  pulmonary  matter. 
The  supervention  of  the  acute  catarrh  usually  brings  on  a  fit  of 
asthma,  or  at  least  aggravates  the  habitual  dyspnoea.  This  is  re- 
lieved by  the  appearance  of  the  expectoration  ;  but  it  frequently 
still  continues  worse  than  before  the  invasion  of  the  new  affection. 
If  fever  comes  on  in  the  course  of  the  acute  catarrh,  it  percepti- 
bly lessens  the  oppression.*  The  same  is  true  of  sleep  ;  and  if 
this  ever  comes  on  during  an  asthmatic  paroxysm,  the  moment  of 
awaking  is  the  only  one  in  which  the  patient  fancies  that  he  can 
breathe  freely.  Nevertheless,  even  during  these  intervals  of  ease, 
the  respiration  examined  by  the  stethoscope,  is  not  at  all  more  per- 
fect than  during  the  severest  paroxysms  ;  a  fact  which  proves  that 
both  fever  and  sleep  act  in  this  case  by  diminishing  the  necessity 
of  respiration. f     The  upright  posiure  is  not  so  constantly  requi- 

*  This  statement  is  doubtful  to  say  the  least.  For  my  part  I  have  never 
come  to  the  knowledge  of  the  fact  on  which  it  is  grounded,  but  have  often  ob- 
served the  contrary. — indral. 

t  Fever  is  so  far  from  diminishing  the  demand  for  respiration,  that  one  of  the 
phenomena  commonly  attending  a  febrile  movement  of  any  intensity  is  an 
aceeleration  of  respiratory  motion,  or  at  least  a  greater  elevation  of  the  walls  of 
the  chest  at  every  inspiration.—  Andral. 


DRY    CATARRH.  101 

site  in  cases  of  asthma  depending  on  the  dry  catarrh,  as  in  oppres- 
sed breathing  produced  by  diseases  of  the  heart,  or  effusions  into  the 
chest.  After  an  extensive  dry  catarrh  has  continued  for  a  certain 
length  of  time,  and  more  particularly  if  aggravated  by  repeated 
attacks  of  the  acute  kind  above  described,  emphysema  of  the 
lungs  supervenes,  with  its  characteristic  signs  and  symptoms. 
The  name  of  neglected  cold  usually  given  to  phthisis,  is  therefore 
applicable  to  this  latter  affection. 

The  dry  catarrh  is  denominated  latent  when  it  is  unattended 
either  by  cough  or  expectoration.  This  variety  is  distinguished 
by  a  very  great  and  usually  unequal  feebleness  of  the  respira- 
tory sound,  over  the  greater  part  of  the  chest ;  by  the  complete 
sonorousness  of  this  cavity  on  percussion ;  and  by  the  occasional 
though  rare  addition  of  a  slight  sibilous  or  obscure  mucous 
rhonchus,  or  very  feeble  sound  of  the  valve :  these  last  signs 
are  of  such  unfrequent  occurrence  that  we  may  explore  the  chest 
several  days  •successively  without  perceiving  them.  The  dry 
catarrh  is  almost  always  latent,  when  slight  and  of  small  extent. 
It  only  then  becomes  an  inconvenience  when  the  tumefaction  of 
the  bronchi  has  increased  sufficiently,  either  in  extent  or  inten- 
sity, to  impede  the  full  development  of  the  lungs  required  during 
exercise. 

The  symptomatic  catarrh  of  fevers  is  almost  always  latent,  par- 
ticularly during  the  first  days  of  the  disease  ;  not  but  that  the 
patients,  in  this  case,  cough  occasionally ;  but  the  cough  is  so 
slight  and  infrequent  as  to  be  either  unattended  to  or  altogether 
overlooked  by  the  physician.  IHs  sometimes,  however,  noticed 
by  the  attendants  when  unobserved  by  the  practitioner.  After 
continued  fevers,  and  mucous  catarrhs  of  long  standing  or  fre- 
quently renewed,  habitual  latent  dry  catarrhs  are  left,  which 
eventually  terminate  in  the  production  of  asthma  and  emphysema 
of  the  lungs. 

The  frequency  of  the  dry  catarrh,  the  insidious  slowness  of  its 
progress,  and  the  severity  of  its  effects  when  arrived  at  its  height, 
ought  to  convince  us  how  necessary  it  is  not  to  consider  as  unim- 
portant affections,  dry  coughs  of  long  standing,  however  slight 
or  infrequent  they  may  be.  These  coughs,  as  T  have  already 
said,  are  the  consequence  of  the  dry  catarrh,  except  in  the  parti- 
cular case  wherein  they  are  caused  by  the  development  of  mi- 
liary tubercles  of  the  lungs. 

Treatment.  The  means  which  are  most  useful  in  relieving 
the  mucous  catarrh,  both  acute  and  chronic,  are  without  effect 
in  the  dry  catarrh  ;  or  if  of  any  use,  it  is  merely  by  the  removal 
of  certain  accidental  symptoms  or  complications,  after  which 
the  disease  returns  to  its  primitive  state.  In  this  way,  blood- 
letting, cither  general  or  local,  may  be  requisite  in  relieving  a 

°lr 


102  DRY    CATARRH. 

determination  of  blood  to  the  lungs  ;  emetics  may  be  beneficial 
on  the  supervention  of  a  fresh  cold  ;  while  paregorics  must  fre- 
quently be  had  recourse  to,  as  well  to  lessen  the  necessity  of  re- 
spiration, as  to  quiet  severe  fits  of  coughing.  Opium  repented 
in  very  small  doses,  I  find  very  efficacious  in  relieving  this  symp- 
tom, and  the  preparation  T  most  commonly  employ  with  this 
view,  is  the  syrup  of  poppies,  in  doses  of  a  tea-spoonful,  and 
given  to  the  extent  of  one  or  two  ounces  daily.  The  kermes 
mineral,  as  well  as  the  other  preparations  of  antimony,  and  also 
squills,  have  never  appeared  to  me  of  any  use  in  the  dry  catarrh, 
except  in  certain  cases  complicated  with  herpetic  affections. 
The  indications  which  naturally  present  themselves  are — to  re- 
lieve the  vascular  congestion  or  sub-inflammatory  state,  which 
exists  habitually  in  the  mucous  membrane  of  the  bronchi,  and  to 
facilitate  the  expectoration  of  the  pearly  sputa.  In  regard  to  the 
first  indication,  I  have  just  stated  that  the  detraction  of  blood  is 
useless;  derivatives,  such  as  dry-cupping,  particularly  if  the 
glasses  are  left  long  enough  to  cause  vesication,  blisters,  emetics, 
and  even  purgatives,  afford  some  slight  but  very  temporary  relief. 
Nevertheless,  one  is  occasionally  under  the  necessity  of  having 
recourse  to  some  applications  of  this  kind ;  and  that  which  I  pre- 
fer is  a  pitch  plaster  powdered  with  tartar  emetic,  applied  be- 
tween the  shoulders.* 

As  to  the  second  indication,  the  removal  of  the  pearly  sputa, 
it  is  evident  that  the  glutinous  tenacity  of  these  is  the  chief 
obstacle  to  their  ready  expulsion  ;  and  I  am  of  opinion  that  we 
possess  means,  if  not  infallible,  at  least  often  efficacious,  in  les- 
sening this  tenacity  of  the  secretions  and  rendering  them  more 
liquid.  This  practice  may  perhaps  seem  to  rest  on  the  exploded 
humoral  pathology,  and  I  must  confess  that  the  theory  of  it 
is  neither  mine  nor  of  this  age.  Sarconef  and  Morgagni,  after 
many  others,  made  this  theory  one  of  the  bases  of  their  practice. 
I  attach  no  value  to  it  as  a  theory ;  but  I  can  state  from  experi- 
ence, that  by  means  of  those  medicines  which  the  chemical  and 
humoral  physicians  of  the  last  three  centuries  considered  as 
proper  to  correct  the  tenacity  of  the  fluids,  I  have  succeeded  in 
procuring  very  great  and  permanent  relief  to  many  individuals 
who  had  long  labored  under  dry  catarrhs  of  great  severity. 
The  means  employed  with  this  view  are  chiefly  the  milder  or 
very  dilute  alkalies.  Those  I  have  been  in  the  habit  of  using 
are  the  following: — 1.  Almond  soap  taken  in  the  form  of  pill, 
with  the  patient's  meals,  to  the  amount  of  from  half  a  drachm 
to  a  drachm  daily.     If  the  catarrh  is   complicated  with  spasm  of 

*  The  line  of  the  spine  musl  be  avoi'ded,  on  account  of  the  excessive  pain  oc 
casioned  by  the  pustules  in  this  place. — Author. 
t  Istoria  ragionata  dc'  Morbi,  etc.  Napoli,  1765. 


DRY    CATARRH.  103 

ihc  bronchi,  (to  be  noticed  hereafter,)  I  sometimes  conjoin  with 
the  pills,  the  gum  ammoniac,  in  the  dose  of  from  eight  to 
twenty-four  grains  in  the  day.  2.  The  salt-water  bath  of  the 
temperature  from  ninety-three  to  ninety-nine  degrees  of  Fahren- 
heit: the  artificial  alkaline  bath,  with  four  ounces  of  the  carbo- 
nate of  potass  or  soda,  and  the  sulphur  baths,  natural  or  artifi- 
cial. •  I  give  the  preference  to  the  last  in  herpetic  cases.  3.  The 
internal  use  of  the  carbonates  of  soda,  potass,  or  ammonia,  in  a 
dose  of  from  twelve  to  thirty-six  grains  per  day,  diffused  in  all 
the  patient's  drink  ;  or  the  sulphureous  saline  mineral  waters, 
particularly  of  Bonnes  and  -Caute^ets. 

The  employment  of  these  means  ought  to  be  persevered  in 
for  several  months  at  least,  even  when  they  afford  the  most 
speedy  relief.  I  have  never  observed  any  ill  effects  from  them, 
and  I  have  frequently  employed  the  soap,  more  especially,  for 
two  or  three  years  without  intermission.  A  great  many  per- 
sons, who  had  already  emphysema  of  the  lungs,  and  either  in- 
cessant dyspnoea,  or  very  frequent  fits  of  asthma,  have,  to  my 
own  knowledge,  been  restored,  under  this  kind  of  treatment,  to 
a  state  of  health  so  comfortable,  that  they  hardly  exhibited  any 
signs  of  disease,  and  considered  themselves  as  entirely  cured. 
After  the  employment  of  these  means  for  a  certain  period,  the 
pearly  sputa  become  more  abundant ;  or  if  there  had  been  pre- 
viously no  expectoration  of  the  sort,  this  now  takes  place.  At 
the  same  time  the  tenacity  of  the  sputa  is  diminished  ;  they  be- 
come diffluent,  and  lose  their  rounded  form ;  and  relief  of  the 
oppression  is  experienced.  This  plan  of  treatment  is  often  most 
efficacious  where  the  disease  is  most  severe.  I  know  not  what 
may  be  thought  of  the  theory  on  which  it  is  founded.  Animal 
chemistry  is  yet  too  imperfect  to  furnish  the  solution  of  the  pro- 
blem.*    No  doubt  it  would  be  better  if  we  could  dispense  with 

*  The  preceding  section  is  one  of  the  most  interesting  and  valuable  in  the 
whole  work.  In  it  I  think  we  have  more  insight  into  the  true  nature  of  one 
very  numerous  class  of  cases  of  asthma,  than  in  all  the  voluminous  writings  of 
authors  on  this  disease;  while  in  the  chapters  on  emphysema  of  the  lungs  and 
on  nervous  asthma,  in  a  subsequent  part  of  the  treatise,  we  have  such  additional 
light  thrown  upon  this  disease,  that  it  mav  •henceforth,  in  a  great  measure*  be 
considered  as  raised  from  the  obscurity  of  hypothesis  into  the  light  of  rational 
pathology.  Once  made  acquainted  with  the  existence  of  the  disease  described 
in  the  preceding  section,  and  its  common  consequence,  emphysema  of  the  lungs, 
we  perceive  their  applicability  to  the  explanation  of  most  of  the  phenomena  of 
the  different  forms  of  asthma  not  dependent  on  disease  of  the  heart.  If  the 
asthmatic  attack  itself  is  the  immediate  consequence  of  a  spasmodic  affection  of 
the  minute  bronchi,  and  this,  I  think,  can  hardly  be  called  in  question — it  must 
lie  admitted  that  the  remote  cause  of  the  spasm,  in  a  great  many  cases,  is  to  be 
found  in  that  condition  of  the  bronchial  membrane  which  constitutes  the  disease 
90  admirably  described  by  our  author  in  the  preceding  section  ;'and  I  am  con- 
\  inced  that  a  very  great  proportion  of  the  tits  of  asthma,  immediately  owe  their 
origin  to  exciting  causes,  which  operate  by  aggravating  the.  habitual  state  of 
disorder  existing  in  the  membrane.     Of  these  causes,  beyond  comparison  the 


104  DRY    CATARRH. 

all  theory  ;  but  this  is  impossible :  the  numerous  and  diverse 
facts  which  constitute  the  science  of  physic,  can  only  be  classed 

most  frequent  is  cold,  or  at  least  that  class  of  agencies,  which,  in  a  different 
degree  and  in  other  circumstances,  give  rise,  in  healthy  or  delicate  subjects,  to 
the  phenomena  of  catarrh.  When  we  consider  that  this  disease  in  fact  habitu- 
ally exists  in  these  persons,  keeping  up  a  most  unnatural  sensibility  in  the 
affected  parts  to  impressions  from  without,  and  when  we  consider,  a1  the  same 
time,  how  easily  a  part  that  is  in  a  state  of  inflammatory  irritation  is  excited  to 
spasm,  we  need  not  be  surprised  at  the.  facility  with  which  the  asthmatic  par- 
oxysms are  excited  by  perceptible  or  imperceptible  causes.  Of  these  exciting 
causes,  as  I  have  already  said,  the  impression  of  cold  or  at  least  the  alternation 
of  temperature,  is  that  which  reasoning  woujd  lead  us  to  expect  to  be  incom- 
parably the  most  frequent,  and  whiclf  we  accordingly  find  to  be  so  in  fact.  A 
minute  investigation  of  all  the  circumstances  attending  the  renewal  of  an  asth- 
matic paroxysm,  will  convince  any  one  of  this,  in  a  great  majority  of  cases.  I 
would  add,  that  in  all  cases  the  exciting  cause  is,  and  in  most  cases  can  be  traced 
to  be,  an  irritant  of  some  kind  or  other,  acting  on  the  too  sensible  membrane  of 
the  bronchi.  This  view  of  the  pathology  of  the  disease  is  supported  by  an 
examination  of  the  facts  recorded  in  all  our  best,  works  on  Asthma,  particularly 
those  of  Floyer,  Withers,  Ryan  and  Bree.  In  the  writings  of  the  first  and  last 
named  authors,  who  studied  the  complaint  in  their  own  persons,  there  is  abun- 
dant evidence  that  the  disease  in  them  was  a  dry  catarrh,  and  that  the  paroxysms, 
in  a  great  majority  of  instances,  were  excited  by  cold.  In  the  case  of  Dr.  Bree 
this  is  more  particularly  evident.  In  the  very  sensible  work  of  Dr.  Ryan,  the 
paramount  influence  of  cold  in  exciting  the  disease,  is  established  by  many  facts, 
and  ingenious  observations.  The  same  influence  is  admirably  illustrated  in 
some  cases  detailed  by  the  late  Dr.  Watt,  in  his  work  on  Diabetes,  ».V.c.  page 
247,  although  a  false  explanation  (I  conceive)  is  given  of  the  rationale  of  its 
operation  in  producing  the  asthmatic  paroxysm. 

As  in  every  other  case,  a  more  correct  pathology  in  this  disease  will  put  us  in 
the  way  of  a  more  rational  practice.  Instead  of  wasting  our  efforts  in  attempt- 
ing to  ward  off  paroxysms  of  a  purely  spasmodic  nature,  by  measures  directed 
to  the  nervous  system,  our  attention  will  be  directed  to  the  removal  of  the  real 
disease,  the  structural  alteration  and  preternatural  sensibility  of  the  bronchial 
membrane.  How  far  the  attainment  of  the  first  gf  these  two  objects,  the  remov- 
ing the  structural  alteration  is  within  our  power,  I  am  not  prepared  to  say  :  but 
I  presume  it  cannot  be  considered  as  essential  to  the  cure  of  the  disease,  since 
we  know  that  this  state  may  and  does  exist,  in  innumerable  cases,  and  for  a  long 
period,  without  producing  asthma.  Neither  shall  I  enquire,  how  far  means 
which  lessen  the  sensibility  of  the  membrane,  tend  to  restore  the  natural  organ- 
ization*. I  think,  however,  both  reason  and  experience  will  bear  us  out  in  ex- 
pecting more  benefit  from  means  that  lessen  the  sensibility  of  the  bronchial 
membrane,  than  from  any  other.  And  with  this  view,  in  addition  to  the  meas- 
ures recommenced  in  the  text,  I  would  here  beg  leave  to  call  the  attention  of 
practitioners  most  particularly  to  the  use  of  the  cold  bath.  This  remedy  was 
rarely  recommended,  and  still  more  rarely  used  by  practitioners,  before  the  pub- 
lication of  Dr.  Ryan's  excellent  work  on  asthma  in  1793.  In  this  work,  tin- 
author  adduces  many  instances  of  successful  treatment  by  the  cold  bath,  and 
recommends  its  adoption  in  very  strong  terms.  Since  Dr.  Ryan's  publication, 
this  plan  has  been  more  frequently  had  recourse  to,  but  much  less  so.  I  conceit  e, 
than  it  ought.  Dr.  Bree  appears  to  have  derived  great  benefit  from  it  in  bis 
own  case,  and  speaks  very  favorably  of  it  as  a  remedy  :  yet,  I  think,  he  dwells 
much  less  upon  its  merits  than  it  would  appear  to  deserve.  I  have  myself  pre- 
scribed it  with  much  benefit.  Every  practitioner  must  be  well  acquainted  with 
the  effect  of  cold  bathing,  in  one  form  or  other,  in  lessening  the  sensibility  of 
the  body  generally,  and  the  lungs  in  particular,  to  the  impressions  of  cold.  In 
my  own  experience,  the  effect  of  sponging  the  chest  with  cold  water  and  salt 
or  vinegar,  once  or  twice  a  day  has  proved  of  immense  benefit  to  delicate  sub- 
jects, and  more  especially  to  those  liable  to  catarrhal  affections,  and  to  persons 
decidedly  phthisical.     In  these  cases,  although  no  doubt,  the  practice  proves 


CONVULSIVE    CATARRH.  105 

in  the  memory  by  the  aid  of  some  systematic  bond.  It  is,  in- 
deed, much  to  be  desired  that  less  importance  were  attributed  to 
views,  which,  after  all,  can  only  be  considered  as  the  scaffolding 
of  the  science ;  and  more  especially  it  is  to  be  wished  that  the 
attachment  to  theory  would  not  lead  many  persons  (as  it  does) 
to  reject  the  very  facts  on  which  other  theories,  whether  ancient 
or  modern,  hostile  to  their  own,  are  founded. 

Sect.     VI. —  Of  the  convulsive  catarrh  or  hooping-cough. 

This  variety  of  the  pulmonary  catarrh  has  much  engaged  the 
attention  of  practitioners,  as  well  on  account  of  its  frequency  as 
its  occasional  severity.  It  holds  the  mid  rile  place  between  the 
pituitous  and  mucous  catarrh,  as  far  as  regards  the  nature  of  the 
expectoration  and  the  bronchial  congestion,  and  it  possesses,  be- 
sides, some  other  characters  peculiar  to  itself.  It  particulasly  " 
attacks  children,  and  seldom  occurs  twice  in  the  same  individual ; 
hence,  no  doubt,  the  general  belief  of  its  contagious  nature.  The 
truth  of  this  opinion  is,  however,  far  from  being  proved ;  and  it 
is  certain  that  the  alteration  of  temperature  is  equally  a  cause 
of  this  as  of  other  catarrhs.  The  cough  in  this  affection  returns 
by  fits,  which  last  a  quarter  of  an  hour  or  more.  Each  fit  is 
composed  of  a  quick  succession  of  sonorous  coughs,  tvith  scarcely 
any  perceptible  inspirations  between ;  except  that  from  time  to 
time  the  expirations  of  coughing  are  suddenly  interrupted  by  a 
very  deep,  seemingly  convulsive  and  noisy  inspiration,  accom- 
panied by^a  lengthened  hissing,  which  constitutes  the  pathogno- 
monic sign  of  this  variety  of  catarrh.  The  face  becomes  swollen 
and  livid  in  the  paroxysms,  and  particularly  before  the  sonorous 
inspiration.  A  colorless  and  scarcely  frothy  but  ropy  phlegm 
rather  flows  than  is  rejected  from  the  mouth,  after  each  paroxysm, 
while  the  patient  leans  forward  to  favor  its  escape.  The  parox- 
ysms at  first  recur  several  times  every  day,  being  almost  always 
more  severe  towards  evening,  but  much  less  so  during  the  night. 
After  a  certain  time,  they  return  only  in  the  morning  and  evening, 
and  towards  the  end  of  the  disease,  in  the  evening  only.     There 

tonic  to  the  system   generally,  I  conceive  its  chief  operation  is  in  lessening  the 
sensibility  of  the  lungs  to  the  impression  of  cold. 

To  the  list  of  remedies  mentioned  in  the  text,  there  are  two  which  ought  to 
be  added  on  account  of  the  celebrity  they  have  obtained  in  this  country  in  the 
cure  of  asthma  :  I  mean  the  oxyd  of  zinc  and  stramonium.  For  a  full  account 
of  the  operation  of  the  former,  I  must  refer  the  reader  to  the  numerous  cases 
treated  by  it  and  recorded  in  Dr.  Wither's  Treatise  on  the  asthma,  published  in 
L786.  tn  many  of  these,  the  remedy  appears  to  have  been  efficacious  ;  although, 
on  the  whole,  I  think  the  author  has  exaggerated  its  importance.  For  ampler 
details  on  the  treatment  of  the  different  forms  of  asthma,  I  refer  the  reader  to 
the  article,  Asthma,  in  the  Cyclopaedia  of  Practical  Medicine,  written  by  the 
translator  of  this  treatise. —  Transl. 

14 


106  CONVULSIVE    CATARRH. 

is  more  of  periodicity  in  this  variety  of  catarrh  than  the  others : 
before  it  goes  off  it  sometimes  assumes  a  tertain  period.  The 
duration  of  the  hooping-cough  varies  from  a  few  weeks  to  several 
months.  Before  it  terminates,  the  paroxysms  become  shorter, 
lose  their  peculiar  characters,  and  are  attended  by  an  expectora- 
tion more  decidedly  mucous.  It  is  not,  however,  easy  to  recog- 
nize this  alteration,  on  account  of  the  habit  of  children  to  swallow 
the  expectoration.  Sometimes  the  disease  degenerates  into  a 
chronic  mucous  catarrh,  with  emaciation  and  other  symptoms  re- 
sembling those  of  consumption.  In  the  intervals  of  the  parox- 
ysms, the  patient  coughs  but  little,  preserves  his  appetite  and 
strength,  and  has  rarely  any  fever  except  in  the  particular  case 
just  mentioned,  or  in  the  onset  of  a  very  severe  attack. 

The  stethoscopic  exploration  of  the  chest  in  the  intervals  of  the 
fits,  supplies  only  the  usual  results  of  catarrh,  namely, — a  feebler 
'respiration  than  natural,  or  the  complete  absence  of  this  in  cer- 
tain points,  which  however  sound  well, — puerile  respiration  in 
other  parts,  and,  occasionally,  a  slight  sonorous  or  sibilous  mucous 
rhonchus.  During  the  fits,  we  can  only  perceive  the  shock  com- 
municated to  the  chest  by  the  cough  ;  or,  at  most,  a  slight  degree 
of  rhonchus,  and  also  of  the  respiratory  sound,  in  the  brief  inter- 
vals between  the  coughs ;  the  natural  sound  of  respiration,  whe- 
ther pulmonary  or  bronchial,  being  inaudible,  even  in  those  parts 
of  the  lungs,  which,  immediately  before  and  after  the  paroxysm, 
give  the  puerile  respiration. 

The  peculiar  sonorous  inspiration,  pathognomonic  of  the  affec- 
tion, appears  to  have  its  seat  exclusively  in  the  larynx  an$  trachea. 
The  absence  of  the  respiratory  sound  during  the  paroxysm,  can 
only  be  explained  by  supposing  a  momentary  congestion,  from 
blood  or  serum,  giving  rise  to  a  tumefaction  of  the  mucous  mem- 
brane sufficient  to  obstruct  the  bronchi,  or  by  a  spasmodic  con- 
traction of  the  same  parts.  The  discovery  made  by  Reissessen* 
of  a  circular  muscular  apparatus  in  the  smaller  bronchi,  would 
satisfactorily  account  for  a  spasmodic  stricture  of  these  parts, 
which  has  been  admitted  in  so  many  diseases  of  the  lungs,  by 
numerous  authors,  without  further  proof  than  that  afforded  by 
the  symptoms.  I  must  confess  that  I  have  in  vain  looked  for  the 
muscular  apparatus  described  by  Reissessen,  in  the  smaller  bron- 
chial ramifications  of  the  human  subject ;  but  their  distinct  ex- 
istence in  the  branches  of  a  larger  calibre, — some  facts  already 
stated  by  me,  and  the  phenomena  of  several  of  the  varieties  of 
asthma,  lead  me  to  regard  as  certain  the  possibility  of  the  tem- 
porary occlusion,  by  spasmodic  contraction,  of  the  smaller  bron- 
chial ramifications.     Be  this  as  it  may,  I  must  remark,  that  the 

*  De  Fabrica  Pulmonis.     Berlin,  1822. 


CONVULSIVE    CATARRH.  107 

spasmodic  character  of  the  hooping-cough  is  sufficiently  evident 
from  the  phenomena  which  occasionally  show  themselves  in  the 
glottis,  larynx,  and  even  in  the  pendulous  veil  of  the  palate.  I 
formerly  observed,  that  the  extraordinary  noises  made  by  certain 
patients  in  breathing,  or  coughing,  are  owing  to  a  spasmodic  or 
voluntary  contraction  of  the  parts  just  mentioned.  The  same  is 
true  of  the  peculiar  sounds  which  attend  the  hooping-cough  ;  and 
also  of  those  of  certain  cases  of  the  dry  catarrh,  commonly  deno- 
minated nervous  or  gastric.  In  both  these  affections  I  have  met 
with  patients  who  crowed  like  a  cock,  or  barked  like  a  dog.  Dr. 
Bally  lately  sent  me  a  patient  with  hooping-cough  in  whom  the 
paroxysms  were  accompanied  by  a  cooing  like  that  of  a  wood- 
pigeon,  and  sufficiently  loud  to  be  heard  at  fifty  paces  distant. 
This  latter  circumstance  at  once  convinced  me  that  the  sound  pro- 
ceeded solely  from  the  fauces,  and  was  owing  to  a  spasmodic  con- 
traction of  the  veil  of  the  palate  and  sides  of  the  glottis  :  an  opinion 
the  truth  of  which  the  application  of  the  stethoscope  at  once  de- 
monstrated. This  opinion  was  still  further  confirmed  by  the  su- 
pervention, a  few  days  afterwards,  of  a  cynanche  tonsillaris :  the 
cooing  disappeared  during  the  continuance  of  the  inflammation, 
and  was  renewed,  but  in  a  less  degree  on  its  subsidence.* 

*  The  opinions  of  the  numerous  authors  who  have  written  on  Hooping-Cough, 
respecting  its  cause,  nature,  and  seat,  are  very  various.  The  completest  view 
that  we  have  of  these  is  given  in  the  work  of  Desruelles,  published  in  1827  ; 
and  to  this  and  the  Treatise  of  Dr.  Watt,  published  in  1813,  the  reader  is  re- 
ferred for  much  ampler  details  respecting  the  disease  generally,  than  are  to  be 
found  in  the  present  work.  Our  author's  account  is  especially  defective  in  the 
history  of  the  earliest  and  latest  stages,  as  he  neither  notices  the  slight  but  im- 
portant symptoms  which  usher  in  the  more  formal  malady,  nor  yet  traces  its 
progress  through  the  ulterior  stages  when  it  terminates  fatally.  This  last  point 
is  particularly  attended  to  in  the  work  of  Dr.  Watt.  The  following  is  a  brief 
synoptical  view  of  the  principal  opinions  promulgated  by  the  moderns  concern- 
ing the  seat  and  nature  of  the  hooping-cough,  with  the  names  of  their  chief  sup- 
porters. It  is  proper,  however,  to  remark,  that  several  of  the  writers  included 
under  the  same  head,  although  agreeing  generally  as  to  the  nature  of  the  disease, 
sometimes  advocate  considerable  and  peculiar  modifications  of  the  common  doc- 
trine. 

1.  A  nervous  disease,  according  to  the  common  acceptation  of  that  term — 
Cullen  ;  Bohme  ;  Guibert. 

2.  An  idiopathic  affection  of  the  pulmonic  and  diaphragmatic  nerves. — Hufe- 
land;  Jahn ;  Lobenstein;  Albers ;  Wendt;  Paldamus. 

3.  A  nervous  affection  of  the  lungs,  from  sympathy  with  other  organs,  but 
chiefly  with  the  stomach  and  bowels. — Stoll ;  Butter;  Waldschmidt;  Cham 
bon  ;  Danz  (?). 

4.  A  catarrh  of  the  lungs  and  stomach.  "  Affection  pneumogastrique  pitui- 
teuse." — Tourtelle. 

5.  The  same,  but  conjoined  with  a  spasmodic  affection  of  the  glottis  and  dia- 
phragm.— Gardien  ;  Millot. 

6.  Primvy  affection  of  the  brain,  exciting  spasmodic  affection  of  the  respira- 
tory apparatus. — Leroy  ;  Boisseau  ;  Webster  ;  Otto  ;  Begin. 

7.  Inflammation  of  the  larynx  and  glottis. — Astruc;  Dawson. 

8.  Primary  bronchitis,  or  pulmonary  catarrh,  inducing  directly  spasm  of  some 
part  of  the  respiratory  apparatus. — Darwin  ;  Watt ;  Marcus  ;  Laennec  ;  Bros- 
sais  ;  Guersent ;  Dewees  ;  Fourcade-Prunel ;  Duges. 


108  CONVULSIVE    CATARRH. 

Treatment. — Bleeding  is  here  as  seldom  useful  as  in  the  other 
varieties  of  catarrh.  Mucilaginous  and  saccharine  apozems  are 
in  this  case,  as  in  others,  merely  expectant,  or  at  most  soothing 
to  the  irritation  produced  by  the  cough  in  the  fauces.  There  is 
one  other  way,  however,  in  which  they  may  exert  a  more  power- 
ful and  direct  effect  on  the  disease.  If  the  patient  can  be  made 
to  drink,  by  small  and  repeated  portions,  during  the  paroxysm, 
this  is  sensibly  diminished  both  in  severity  and  duration  ; — the 
effort  of  deglutition  favoring  and  producing  deeper  inspirations, 
probably  by  counteracting  the  spasm  of  the  bronchi.*  No  means 
are  more  useful,  at  the  commencement  of  hooping-cough,  than 
emetics,  repeated  every  day  or  every  second  day,  for  one  or  two 
weeks.  Children  are  well  known  to  support  this  kind  of  treat- 
ment better  than  adults  ;  and  I  even  give  the  preference  in  their 
case,  to  emetic  tartar  over  ipecacuan,  as  well  on  account  of  the 
great  inequality  of  power  in  the  latter,  as  because  the  former,  on 
account  of  its  solubility,  is  much  more  easily  administered  in 
doses  proportioned  to  the  exigency  of  the  case.  After  emetics, 
narcotics  in  small  doses  are  generally  very  beneficial.  Much  has 
been  said,  of  late  years,  of  the  extract  and  recent  powder  of  the 
belladonna ;  and  I  consider  it  to  be  superior  to  other  plants  of  the 
same  family.  The  dose  is  from  an  eighth  to  half  a  grain.  Its 
efficacy  in  lessening  the  severity  of  the  cough,  and  shortening 
the  duration  of  the  disease,  may  be  accounted  for  in  several  ways : 
it  lessens  the  necessity  of  respiration,  and  consequently  dyspnoea, 
more  certainly  than  any  other  narcotic :  and  it  seems  proper,  like 
all  the  medicines  of  this  class,  to  obviate  the  spasm  of  the  bron- 
chi, to  diminish  the  irritation  produced  in  these  by  the  vascular 
congestion  of  their  mucous  membrane,  and  to  lessen  its  aug- 
mented secretion.  The  extract  of  common  daffodil  (narcissus 
pseudo-narcissus,  L.)  and  also  the  infusion  of  its  petals,  were 
proposed,  some  years  since,  as  a  sort  of  specific  against  this  dis- 
ease. I  have  used  the  extract  much,  and  have  occasionally  seen 
it  effect  surprisingly  rapid  cures, — for  instance,  in  five  or  six 
days  ;  but  this  result  is  rare  ;  and  as  a  general  remedy  I  find  it 
much  less  efficacious  than  belladonna.  The  usual  mode  of  ad- 
ministering the  pseudo-narcissus,  is  to  give  half  a  grain,  a  grain, 
or  two  grains,  every  two,  four,  or  six  hours,  according  to  the 
patient's  strength.  Its  mode  of  action  is  yet  imperfectly  known. 
In  a  pretty  large  dose,  it  exerts  a  very  conspicuous  influence  over 

9.  Primary  Bronchitis  inducing  cephilic  irritation,  and  this  in  its  turn  exciting 
the  spasmodic  affection  of  the  respiratory  organs.— Desruelles.  • 

10.  Insects  irritating  the  bronchial  membrane.— Rosenstein  ;  Linnaeus. 

■  Transl. 

*  It  is  well  known  that  several  species  of  animals,  such  as  the  tortoise,  frog, 
&C,  whose  thorax  is  immovable,  perform*  inspiration  only  by  means  of  deglu- 
tition.— Author. 


CONVULSIVE    CATARRH.  109 

the  nervous  system,  and  even  produces  convulsions.  When  the 
paroxysms  of  hooping-cough  assume  a  periodical  type,  cinchona 
or  the  sulphate  of  quinine,  given  as  in  cases  of  ague,  are  often 
as  efficacious  as  in  this  disease.  I  have  seldom  found  blisters  of 
much  use.  Autenrieth  has  proposed,  as  a  substitute  for  these, 
the  tartar  emetic  ointment  applied  in  succession  to  different  parts 
of  the  chest.  I  have  occasionally  found  more  benefit  from  this 
than  front  blisters.  Frictions  with  oil,  over  the  whole  surface  of 
the  body,  have  been  recommended  as  the  principal  means  of 
treatment  by  Poutingon ;  and  I  have  sometimes  derived  _  benefit 
from  their  employment.  I  have  also  seen  good  effects  from  these 
in  certain  cases  of  the  chronic  dry  catarrh,  where  the  disease 
was  constantly  aggravated  by  the  supervention  of  acute  attacks  on 
the  slightest  alteration  of  the  weather.  This  mode  of  increasing 
the  cutaneous  perspiration,  which  constituted  so  important  a  part 
irl  the  hygeine  of  the  ancients,  has  certainly  been  too  much  neg- 
lected by  the  moderns.* 

*  In  the  very  brief  notice  of  the  treatment  adapted  to  this  disease,  given  by 
our  author,  many  modes  of  practice,  at  least  as  beneficial  as  those  mentioned, 
have  been  overlooked.  Notwithstanding  the  condemnation  of  bleeding  in  the 
text,  it  is  unquestionably  very  proper  in  many  cases,  and  in  some  absolutely 
necessary.  In  directing  its  employments,  which  is  indicated  chiefly  by  the  su- 
pervention of  more  formal  inflammation  in  the  bronchi  o'f  lungs,  the  stethoscope 
is  of  great  use. 

In  a  short  but  excellent  article  on  this  disease,  by  Dr.  Johnson  of  Dublin, 
in  the  Cyclopaedia  of  Practical  Medicine,  the  attention  of  the  practitioner  has 
been  most  judiciously  called  to  the  more  important  affections  which  complicate 
hooping-cough,  as  the  points  on  which  the  event  of  the  (Jisease,  at  least  in  the 
severer  cases,  often  hinges.  The  chief  complications  noticed  by  him  are,  peri- 
pneumony,  gastric, .or  infantile  remittent  fever,  and  hydrocephalus.  In  each  of 
these  complications  the  treatment  of  the  superadded  disease  is  of  much  more  im- 
portance than  that  of  the  primary  hooping-cough.  In  these  complications  leeches 
to  the  head  or  chest,  or  prsecordia,  may  be  respectively  most  useful,  as  well 
as  other  kinds  of  treatment  applicable  in  such  cases.  Many  medicines  supposed 
to  possess  a  specific  power  in  curing  the  disease  have  been  recommended  by  va- 
rious authors,  and  are  still  in  constant  use,  either  by  practitioners  or  the  vulgar. 
Some  of  these,  if  not  all,  have  been  found  beneficial  in  various  cases;  and 
most  of  tbem  may  admit  of  a  trial,  without  risk,  in  the  latter  stages  of  the  dis- 
ease,  when  no  inflammatory  complication  exists.  I  copy  the  list  as  given  by 
Dr.  Johnson  : — Opium,  cicuta,  belladonna,  digitalis,  bark,  cupmoss,  arsenic,  ni- 
trate of  silver,  assato'tida,  castor,  musk,  artificial  musk,  camphor,  oil  of  amber, 
meadow  narcissus,  the  alkalies,  antimony,  cantharides,  acetate  of  lead,  cochineal. 
As  the  most  important  of  all  I  would  add,  change  of  air.  (See  Dr.  Clark's  work 
on  the  Influence  of  Climate.) — Transl. 

LITERATURE  OF  HOOPING-COUGH. 

Tbe  following  arc  the  principal  distinct  works  on  hooping-cough,  arranged 
nearly  in  the  order  of  their  publication.  It  is  hardly  necessary  to  remark,  that 
the  disease  is  also  treated  of  in  most  of  our  general  systematic  works,  and  in 
the  treatises  on  diseases  of  children.  References  to  these,  as  well  as  to  the 
multitude  of  Theses,  on  Hooping  Cough  in  the  University  Collectious,  and  to 
the  almost  innumerable  papers  in  the  transactions  of  societies  and  the  medical 
journals  of  different  countries,  would  swell  this  notice  to  an  inconvenient  and 


110  SYMPTOMATIC    CATARRH. 

Sect.  VII. — Of  symptomatic  catarrhs. 

Pulmonary  catarrh  co-exists  habitually  with  a  great  many  af- 
fections of  the  pleura  and  lungs,  and  likewise  with  most  diseases 
of  a  general  nature,  such  as  fevers  of  all  kinds,  gout,  scurvy,  &c. 

A  long  and  attentive  observation  of  the  phenomena  of  disease, 
both  in  the  living  and  dead  body,  has  lead  me  to  the  conclusion 
which  I  am  now  about  to  state  ;  and  I  am  convinced  that  the  re- 
petition of  the  same  means  will  lead  others  to  the  same  results : 
nothing  proves  that  the  severest  and  most  prolonged  catarrh  tends 
to  produce  any  other  affection  of  the  chest,  if  we  except  (and 
this  is  of  very  rare  occurrence)  emphysema  of  the  lungs  and  dila- 

disproportionate  size.     And  I   may   take    this  opportunity  of  stating  that  the 
same  remark  applies  to  all  the  bibliographical  notices  in  the  present  work. 

1765.  Williams  (John.)     Histories  of  wounds  of  the  head,  with  remarks  on  the 

convulsive  cough.     Falmouth,  8vo. 
1767.  Fothergill  (J.,  M.D.)     Letter  on  the  cure   of  chincough.     Lond.  (Med. 

Obs.  §  Inq.  vol.  iii.) 

1769.  Millar  (John,  M.D.)  Observ.  on  the  asthma  and  hooping  cough.     Lond. 

8vo. 

1770.  Mellin  (C.  J.)     Von  dem  keickhusten  der  kinder.     Frankf.  8vo. 

1773.  Butter  (W.,  M.D.)     Treatise  on  the  kinkcough.     Lond.  8vo. 

1774.  Kirkland    (Thos.)     Pertussis.     Animadversions  on   the  late   treatise   on 

kinkcough.     Lond.  8vo.  (anon.) 
1776.  Holdefreund    (F.  R.  S.)     Von    epidemischen   stickhusten    der    kinder. — 

Helm.  8vo. 
1786.  Hayes  (Th.)     A  serious  address  on  coughs,  with  obs.  on  hooping  cough. 

3rd  Ed.  Lond.  8vo. 

1790.  Meltzer  (F.  K.)     Abhandlung  vom  keichhusten.     Lcipz.  8vo. 

1791.  Danz  (F.  G.  W.)     Versuch  eincr  allgemein.  geschichte  des  keichhusrtens. 

Marb.  8vo.  (2nd  Ed.  1802.) 
1794.  Jones  (Gale.)     Obs.  on  the  nature   and   treatment  of  the  hooping  cough. 

Lond.  8vo.  (Brunonian.) 
1798.  Burton  (J.  M.  B.,  M.D.)     A  treat,  on  the  non-naturals,  with  an  essay  on 

chin  cough.     York.  8vo. 
1805.  Paldamus  (V.  H.  L.)     Der  Stickhusten  nach  neuern  ansichten  bearbeitet. 

Halle.  8vo. 

1808.  Jahn  (F.)     TJeber  den  keichhusten.     Rudolst.  8vo. 

1809.  Lando  (V.)     Memoria  sopra  la  tosse  in  Genoa  nell'  anno  1806.     Ge- 

noa. 8vo. 
1811.  Loebenstein-Loebel  (E.)     Erkenntniss  und   heilung  der  hautigen  braunc, 

des  keichhustens,  &c.     Leipz.  8vo. 
1813.  Watt  (Rob.,  M.D.)     A  treatise  on  the  chin  cough.     Glasgow.  8vo. 
1813.  Clossius  (J.)     Etwas  ueber  die  quellen,  &c.  des  keuchh.  der  kinder. — 

Hudam.  8vo. 

1815.  Penada  (Giac.)     Memoria  sulla  tosse  convulsiva.     Verona.  8vo. 

1816.  Marcus  (A.  F.)  Der  keichhusten,  ueber  seine  erkenntniss,  &c.  Leipz.  8vo. 

1821.  Id.     Traite  de  la  coqueluche.     Trad,  par  E.  L.  Jacques.     Paris.  8vo. 

1822.  Waterhouse  (J.)  On  tussis  convulsiva  or  whooping  cough.     Boston.  8vo. 
1824.  Peirson  (A.  L.)     Medical  dissertation  on  chin  cough.     Salem.  8vo. 
1827.  Desruelles  (H.)     Traite  de  la  coqueluche.     Paris.  8vo. 

1813.  Gardien.     Diet,  des  Sc.  Med.  t.  6. 

1823.  Guersent.     Diet,  de  Med.  t.  6. 

1830.  Duges.     Diet,  de  Med.  et.  de  Chir.  Prat.  t.  5. 
1833.  Johnson.     Cyclopaedia  of  Practical  Med.  vol.  ii. 

Willes.     Sydenham.     Morton.     Cullen.     Frank.     Good.— Transl. 


SYMPTOMATIC    CATARRH.  Ill 

tation  of  the  bronchi ;  whilst,  on  the  other  hand,  there  is  scarcely 
a  single  disease  of  the  lungs  and  pleura,  which  does  not,  from  its 
very  onset,  give  rise  to  cough  and  expectoration,  in  other  words, 
to  catarrh.  The  greater  number  of  peripneumonies  come  on  sud- 
denly ;  some  cases  supervene  to  a  catarrh,  acute  or  chronic ;  but 
nothing  is  more  uncommon  than  to  see  a  peripneumony  succeed 
to  a  catarrh  of  such  severity  as  to  lead  us  to  attribute,  with  any 
degree  of  probability,  the  origin  of  the  former  to  the  extension  of 
the  inflammation  from  the  mucous  membrane.  It  is  still  rarer  to 
witness  the  origin  of  pleurisy  under  these  circumstances.  On  the 
other  hand,  there  is  scarcely  any  case  of  pleurisy  or  peripneumo- 
ny, even  latent,  which  is  not  accompanied,  at  least  towards  its  close, 
with  catarrhal  expectoration.  In  the  latter  disease,  more  espe- 
cially, this  expectoration  is  sometimes  so  copious,  and  the  catarrhal 
symptoms  so  strongly  marked,  as  to  mask  the  symptoms  of  pe- 
ripneumony, in  the  apprehension  of  practitioners  who  are  unac- 
quainted with  more  precise  signs  of  those  affections.  This  com- 
plication constitutes  the  peripneumony  notha  of  Sydenham,  the 
angina  bronchialis  of  Stoll,  and  the  false  fluxion  on  the  chest 
of  the  French  practitioners  of  the  last  century. 

Phthisis  pulmonalis  has  been  considered,  even  up  to  the  pre- 
sent time,  as  a  frequent  consequence  of  pulmonary  catarrh.  Bayle 
was  the  first  to  attack  this  opinion.  M.  Broussais,  who  had  sup- 
ported it  at  a  time  when  no  one  thought  of  calling  its  truth  in 
question,  still  defends  it.*  This  question  is  of  sufficient  impor- 
tance to  merit  a  particular  investigation,  and  I  shall  return  to  it 
when  treating  of  consumption.  At  present  I  shall  content  my- 
self with  observing,  that  we  see  a  thousand  instances  of  catarrh 
for  one  of  phthisis ;  and  that  we  hardly  ever  meet  with  a  case  of 
the  latter  disease  which  arrives  at  a  fatal  termination,  without 
exhibiting  after  the  nature  of  it  has  become  clear,  an  abundant 
catarrhal  expectoration.  Besides,  this  kind  of  expectoration  con- 
stitutes always  the  greatest  portion  of  the  sputa  of  phthisical 
subjects. 

One  of  the  most  interesting  results  with  which  auscultation 
has  furnished  me,  is  the  constant  presence  of  a  catarrhal  affec- 
tion of  the  lungs,  either  latent  or  manifest,  during  the  whole 
course  of  continued  fevers.f     At  the  commencement,  and  most 

*  Phlegmasies  Chron.  Paris,  1821. 

t  One  of  the  most  unexpected  results  of  auscultation  has  been  the  knowledge 
of  this  remarkable  congestion  of  the  mucous  membrane  of  the  bronchi,  which 
exists  in  nearly  all  cases  of  continued  fever,  while  at  the  same  time,  neither 
cough,  nor  oppressed  breathing,  nor  pain  in  the  chest,  nor,  in  a  word,  any  other 
sign  is  present  to  cause  a  suspicion  of  the  existence  of  disease  in  the  air  tubes. 
A  sibilous  rhonchus,  variable  in  extent  and  intensity  is  the  most  common  sign 
of  this  bronchial  engorgement.  Sometimes  it  passes  into  the  sonorous  rhon- 
chus ;  sometimes  it  is  mingled  with  the  mucous  rhonchus  :  but  in  this  last  case 
there  is  commonly  a  cough  ;  and  in  many  instances  as  this  augments,  the  mucous 


112  SYMPTOMATIC    CATARRH. 

commonly  through  the  whole  period  of  the  fever,  the  catarrh 
is  latent,  without  cough  or  expectoration,  and  only  to  be  dis- 
covered by  the  stethoscope.  Sometimes  it  becomes  manifest  on 
the  approach  of  a  crisis  ;  and  indeed  the  crisis  by  expectoration, 
noticed  by  the  ancients,  and  which  I  have  myself  had  frequent 
occasions  to  remaik,  are  neither  more  nor  less  than  this  catarrh. 
Catarrhal  fevers,  are  those  in  which  the  catarrh  just  stated  to  be 
inseparable  from  continued  fevers,  early  unmasks  itself,  and 
gives  rise  to  a  copious  mucous  expectoration.  The  same  term 
has  also  been  applied  to  those  violent  catarrhs  which  are  ac- 
companied by  a  symptomatic  fever ;  but  in  this  case  the  fever, 
though  considerable  at  first,  and  often  of  long  continuance,  soon 
loses  the  character  of  acute  fevers,  terminating  long  before  the 
catarrhal  affection,  and  never  presents  that  combination  of  cere- 
bral congestions  and  abdominal  disorder,  more  or  less  severe, 
exhibited  by  true  idiopathic  fevers,  which  must  be  considered 
as  diseases  affecting  at  the  same  time  a  great  many  organs,  and, 
perhaps,  still  more  particularly  the  fluids.*  In  eruptive  fevers 
the  pulmonary  catarrh  is  equally  constant,  and  most  commonly 
in  them  it  is  manifest.  In  measles  it  is  well  known  always  to 
be  so ;  and  it  continues  often  for  a  long  time  after  this  disorder 
is  cured.  The  same  thing  occasionally  takes  place  after  simple 
continued  fevers ;  but  in  these,  I  have  also  had  frequent  occasion 
to  observe,  that  when  a  crisis  takes  place,  at  the  very  time  when 
the  lateritious  sediment  shows  itself  in  the  urine,  every  sign  (even 
stethoscopic)  of  perhaps  a  very  intense  and  extended  catarrh 
disappears  at  once,  with  the  coma,  tympanitic  affection,  quick 

rhonchus  becomes  more  distinct.  There  arc,  finally,  examples  in  which  we 
discover  in  the  posterior  part  of  one  or  both  lungs  a  sub-crepitous  rhonchus, 
which  is  not  attended  by  any  manifest  signs  of  inflammation  of  the  lungs  or 
bronchi.  I  have  known  this  last  rhonchus  to  continue  many  days  in  patients 
with  fever,  who  at  the  same  time  coughed  but  once  or  twice  in  twenty-four  hours, 
and  experienced  no  difficulty  of  breathing.  Whatever  may  be  the  nature  of 
the  rhonchi  heard  during  a  fever,  the  extent  of  surface  over  which  they  may  be 
heard,  is  variable.  In  some  cases  the  rhonchus  is  to  be  heard  only  within  very 
narrow  limits,  while  in  the  remaining  parts  of  the  lungs  the  respiratory  murmur 
exists  in  all  its  purity.  In  other  cases,  on  the  contrary,  instead  of  the  vesicular 
respiration  some  one  of  the  rhonchi  is  heard  in  every  part  of  the  lungs,  yet, 
which  is  a  remarkable  fact,  the  patients  suffer  little  or  no  difficulty  of  respiration. 
Under  these  circumstances  an  error  of  diagnosis  may  be  easily  committed  :  the 
existing  lesion  may  be  mistaken  for  the  mere  effect  of  a  pulmonary  disease, 
detected  by  auscultation.  Yet  the  entire  disease  is  not  confined  to  the  lungs 
any  more  than  in  cases  of  bronchial  congestion  which  precedes  and  accompa- 
nies the  eruption  of  measles,  or  in  the  redness  of  the  pharynx  which  accompa- 
nies'the  eruption  of  scarlatina.  In  these  different  cases,  as  in  many  others,  the 
local  lesions,  whatever  their  situation  or  importance,  are  nothing  more  than 
secondary  effects  of  a  general  morbid  cause  acting  upon  and#influencing  the 
whole  system. — Indral. 

The  facts  upon  which  this  assertion  is  grounded,  appear  to  me  such  as  to 
demand  a  further  scrutiny  before  they  can  be  admitted  as  established  fact. 
There  is  reason  to  fear  that  Laennec's  view  of  them  has  been  influenced  by 
the  force  of  theory. — Andral. 


SYMPTOMATIC    CATARRH.  113 

pulse,  heat,  and  earthy  character,  of  the  skin.  During  the 
paroxysms  of  intermittent  fevers,  the  stethoscope  detects,  in  like 
manner,  symptoms  of  catarrh,  for  the  most  part  dry  and  latent, 
and  of  which  some  traces  remain  in  the  intervals.  Even  the 
fevers,  which  are  most  decidedly  symptomatic,  for  instance,  those 
arising  from  a  wound,  very  commonly  present  the  same  pheno- 
mena. It  would,  therefore,  seem,  that  the  first  effect  of  febrile 
action  is  to  produce  a  congestion  in  the  mucous  membrane  of  the 
bronchi :  and  this  effect  is  readily  conceived  on  taking  into  con- 
sideration the  energy  of  the  actions  of  concentration  and  expan- 
sion which  constitute  fever.*  The  inflammatory  fever  of  noso- 
logists,  that  is,  the  fever  characterised  by  a  flushed  countenance, 
moist  and  clean  tongue,  and  a  moist  and  moderately  hot  skin,  is 
of  all  fevers  that  in  which  the  marks  of  dry  catarrh  are  the  least 
perceptible.  I  have  even  observed  two  cases  of  this  fever  in 
which  the  sound  of  respiration  through  their  whole  course,  was 
uniformly  strong  and  pure,  that  is,  unmixed  with  any  kind  of 
rhonchus,  over  the  whole  extent  of  the  lungs.  It  may  here  be 
remarked,  that  this  species  of  fever  is  of  all,  the  least  liable  to 
change  into  another  form ;  that  it  is  rarely  accompanied  by 
symptoms  of  any  considerable  degree  of  cerebral  congestion ; 
that  it  is  hardly  ever  attended  by  signs  of  irritation,  or  by  erup- 
tions or  ulcerations  of  the  mucous  membrane  of  the  intestines, 

*  "  Cet  effett  se  coneoit  facilement  d'apres  l'energie  des  mouvement  de  concen- 
tration  et  d' expansion  qui  constituent  la  fievre."  Although  I  have  translated 
this  paragraph,  I  cannot  say  that  I  quite  understand  it.  The  statement  of  facts 
immediately  preceding  it,  is  very  intelligible,  and  of  extreme  importance,  both  in 
a  pathological  and  practical  point  of  view.  The  reader  will  not  fail  to  observe, 
in  many  parts  of  this  work,  a  very  marked  hostility  to  the  doctrines  of  M .  Brous- 
sais  ;  and  no  doubt  this  discovery  of  the  constant  affection  of  the  bronchial  mem- 
brane in  fever,  is  considered  by  our  author  as  militating  most  powerfully  against 
the  exclusive  doctrine  of  that  pathologist.  In  a  practical  point  of  view,  how- 
ever, I  only  see  in  it  a  cause  for  extending  the  general  principle  of  treatment  ad- 
vocated by  Broussais. 

I  would  be  disposed  to  look  upon  Laennec's  demonstration  of  the  universal 
presence  of  bronchial  congestion  in  fever  as  an  additional  argument  in  favor  of 
the  existence  of  a  similar  state  of  the  mucous  membrane  of  the  stomach  and  in- 
testines, and  would  deduce  the  practical  conclusion  from  it,  that  we  should  also 
endeavor  to  relieve  the  former  as  well  as  the  latter,  by  topical  applications  and 
the  religious  avoidance  of  all  stimuli.  The  opinion  of  our  author,  that  the  con- 
gestion of  the  mucous  membrane  is  the  effect  and  not  the  cause  of  the  first  febrile 
movement,  is  certainly  more  tenable  than  the  reverse;  but  the  admission  of  its 
being  the  effect  of  the  first  movements,  is  almost  equivalent,  in  a  practical  point 
of  view,  to  the  admission  of  its  being  the  cause  of  these. 

The  investigations  of  the  French  pathologists  leave  no  doubt  as  to  the  very 
frequent  affection  of  the  gastro-intestinal  mucous  membrane  in  fever  ;  the  facts 
just  stated  by  Laennec  equally  demonstrate  the  affection  of  the  mucous  membrane 
of  the  lungs  ;  may  we  not,  therefore,  presume,  that  many  other  parts  of  the  sys- 
tem are  in  an  analogous  state  ?  And,  in  reference  to  this  opinion,  may  we  not 
consider  the  state  of  the  tongue  (a  mucous  surface,  and  indeed  a  portion  of  the 
great  intestinal  mucous  membrane)  as  an  index  of  the  existence  of  this  affection 
of  the  mucous  system,  somewhere  t — Transl. 

15 


114  SYMPTOMATIC    CATARRH. 

or  by  a  tympanitic  state  of  the  same  ;  and,  lastly,  that  it  is  al- 
most the  only  fever  in  which  the  blood  exhibits  the  inflamma- 
tory crust.  In  all  these  respects,  then,  the  inflammatory  fever 
appears  to  differ,  either  in  its  nature  or  cause,  from  other  con- 
tinued fevers  ;  it  is  unquestionably  the  most  simple  of  any,  and 
can  least  of  all  be  considered  as  a  primary  affection  of  the  solids. 
Pulmonary  catarrh  is  occasionally  a  striking  symptom  of  per- 
nicious remittent  fevers.  This  appears  to  have  been  the  case  in 
the  epidemic  catarrhal  fever  of  1778,  since  we  find  a  French 
Medical  Society  about  this  time  giving  it  as  a  prize  question, — 
"  To  ascertain  the  relations  of  remittent  catarrhal  and  perni- 
cious fevers"* 

*  LITERATURE  OF  CATARRH  AND  BRONCHITIS. 

1556.  Paparella  (Sebast.)     De  Catarrho  Lib.  II.     Venet.  18mo. 

1565.  Botallust  (L.)     Comment,  de  Catarrho.     Ludg.  4to. 

1597.  Kunrath  (H-)     Vpn  allerlei  fluessen  und  Katarshen.     Leipz.  18mo. 

1611.  Duval  (Jacq.)     Methode  de  guerir  les  catarrhes.     Rouen.  12mo. 

1615.  Paschettus  (Bart.)     De  destillatione,  catarrho  vulgo  dicta.     Venet.  4to. 

1624.  Virgirius  (Joan.)     Tractatus  de  catarrho.      Genev.  l2mo. 

1650.  Helmont  (J.  B.  Van.)     Deliramenta  catarrhi.     Transl.  by  Dr.  Charlton. 

Lond.  4 to. 
1664.  Schneider  (Con.  Vict.)     De  Catarrhis.     Witteb.  4to. 
1696.  Graetz  (J.  H.)     Epistola  de  arteria  et  vena  bronchiali  necnon  de  polypi* 

bronchiorum  ejectis.     Amst.  4to. 
1761.  Lower  (R.,  M.D.)     De  catarrho.     Lond.  8vo. 

1761.  Chandler  (J.)     A  treatise  on  the  disease  called  a  cold.     Lond.  8vo. 
1763.  Baker  (Sir  G.,  M.D.)     De  catarrho  et  dysenteria  Londiensi.     Lond.  4to. 
1776.  Moneta  (C.  J.  de.)     Abhandl.  dass  die  kalte  und  das  kalte  wasser  in  ka- 

tarrh-kranheiten  die  beste  huelfsmittel  sind.      Warschau.  8vo. 
1786.  Hayes  (Th.)     A  serious  address  on  the  cons,  of  neglecting  coughs. — 

Lond.  8po. 
1789.  Mudge  (John.)     A  radical  cure  for  a  catarrhous  cough.     Lond.  8vo. 
1792.  Beddoes  (Th.,  M.D.)     Observations  on  calculus,  catarrh,  &c.     Lond.  8vo. 
1795.  Davidson  (W.)     Observations  on  the  pulmonary  system.     Lond.  8vo. 
1797.  Kelson  (T.  M.)     Remarks  on  the  nature  and  cure  of  colds.     Lond.  8vo. 

1799.  Romain  (       )     Essai  sur  la  maniere  de  traiter  les  catarrhes.    Verdun.  8vo. 

1800.  .Ibbeken  (       )     Ueber  die  gefahr  des  schnupfens.     Stettin.  12mo. 
1802.  La  Roche  (B.)     Essai  sur  le  catarrhe  pulmonaire  aigu.     Paris.  8vo. 
1804.  Tode  (J.  C.)     Ueber  Husten  und  schnupfen.     Kopenh.  8vo. 

1807.  White  (E.  L.)     A  popular  essay  on  the  disease  termed  a  cold.  Lond.  8vo. 

1808.  Broussais  (F.  I.  V.)     Histoire  des  phlegmasieschron.     Par.  3rd  ed.  1826. 

1807.  Cabanis  (P.  J.  G.)     Observations  sur   les  affectiones   catarrhales.     Pa- 

ris. 8vo. 

1808.  Badham  (Ch.,M.D.)     Observations  on  the  inflammatory  affections  of  the 

mucous  membrane  of  the  bronchi.     Lond.  12mo. 

1809.  Cheyne    (J.,  M.D.)     The  pathol.  of  the  memb.  of  the  larynx,  &c— 

Edin.  8vo. 
1813,  Duncan  (A.,  M.D.)     Obs.  on   the   different  species   of  consumption  — 

Ed.  8vo.  v 

1813.  Traweitschek  (J.  J.  N.)  Naturand  heilung  des  nasenkatarrhs.  Bruns.  8vo. 

1813.  Renauldin.     Diet,  des  Sc.  Med.     (Art.  catarrhe.)  t.  4.     Par.  8vo. 

1814.  Badham  (Ch.  M.D.)     An  essay  on  bronchitis,  2nd  ed.     Lond.  12mo. 
1818.  Armstrong  (J.,  M.D.)  .  Practical  observations  on  scarlet  fever,  &c— 

Lond.  8vo.  ' 

1820.  Hastings  (Ch.,  M.D.)     Treat,  on   infl.  of  the  muc.  memb.  of  the  lungs 

Lond.  8vo.  6 


DILATATION    OF    THE    BRONCHI.  115 

Gouty  persons  are  very  subject  to  pulmonary  catarrhs,  parti- 
cularly when  the  gout  has  ceased  to  be  regular ;  and  in  them  the 
disease  puts  .on  the  character  of  the  chronic  mucous  catarrh,  and 
sometimes  of  the  suffocative.  Scurvy,  chronic  eruptive  diseases, 
and  in  general  all  those  affections  wherein  there  exists  a  well- 
marked  cachectic  state,  are  often  accompanied  by  a  catarrh,  either 
manifest  or  latent. 


CHAPTER  II. 


OF    DILATATION    OF    THE    BRONCHI. 


The  organic  lesion  which  I  am  now  to  notice,  seems  to  have 
been  hitherto  entirely  overlooked,  both  by  the  anatomist  and  the 
practitioner.  This  oversight  is  easily  accounted  for,  from  the 
circumstance  of  its  generally  occurring  in  a  small  portion  of  a 
bronchial  tube,  and  of  its  being  mistaken,  when  observed,  for  a 
larger  branch.  It  can  only  be  detected  by  tracing  the  individual 
bronchial  tubes  to  their  ultimate  ramifications, — a  thing  which  is 
rarely  done  in  our  examination  of  the  lungs. 

Anatomical  characters.  This  disease  presents  itself  in  various 
forms.  Sometimes  it  exists  in  one  or  in  several  branches,  or  even 
over  almost  the  whole  extent  of  one  lung,  without  any  other 
change  in  the  appearance  of  the  affected  bronchi,  than  increase  of 
volume:  thus,  ramifications  which  in  the  natural  state  would 
scarcely  admit  a  fine  probe,  acquire  a  diameter  equal  to  that  of 
a  crow-quill,  or  goose-quill,  or  even  of  the  finger.  These  dilated 
branches  frequently  spring  from  a  trunk  of  much  smaller  diame- 
ter than  their  own.  Occasionally  we  find  the  dilated  branch 
resuming  all  at  once  its  natural  size  :  mpre  commonly  it  appears 
to  terminate  in  an  irregularly  shaped  cul-de-sac,  into  which 
several  small   branches  of  a  natural  size  are  found  to  open.     I 

1820.  Alcock  (Thos.)     On  inflammation  of  the  mucous  membrane  of  the  lungs. 

(Med.  Intelligencer  No.  7,  8.)     Lond.  8vo. 
1822.  Chomcl.     Diet,  de  med.     (Art.  catarrhe.)  t.  4.     Par.  8vo. 
1824.  Andral  (G.)     Clinique  medicale,  tome  II.     Par.  1824,  8vo. 
1826.  Porter  (W.  H.)     On  the  surgical  pathology  of  the  larynx,  «fcc.     Dub.  8vo. 
1826.  Gendrin   (A.  N.)     Histoire   anatomique   des    inflammations.     2  vols. — 

Par.  8vo. 

1830.  Roche.     Diet,  de  Med.  et  de  Chir.     (Art.  branchite.)  t.  4.     1830. 

1831.  Horn.     Encyclopaed.     Woeterbuch.  (Art.  bronchitis.)  B.  6.     Berlin.  8vo. 
1833.  Williams.     Cyclopaedia  of  practical  medicine.  Vol.  I.  (Art.  catarrh,  co- 

ryza,  bronchitis.)     Lond. 
Forestus,  Willis,  Morton,  Stoll,  Sydenham,  Botallus,  <fec.  &c.  Sec. 

Transl. 


116  DILATATION    OF    THE    BRONCHI. 

have  never  observed  a  dilatation  which  seemed  to  exist  in  tin* 
ultimate  division  of  the  bronchi,  and  which  could  throw  any 
light  upon  the  manner  in  which  these  terminate.  At  other  times, 
the  dilated  bronchi  lose  their  natural  shape,  and  present  them- 
selves under  the  form  of  a  cavity,  capable  of  containing  a  hemp- 
seed,  a  cherry-stone,  an  almond,  or  even  a  walnut.  Several  sec- 
cessive  enlargements  of  this  kind  may  exist  in  the  course  of  the 
same  tube.  Sometimes  the  dilatation  is  confined  to  one  or  two 
branches  in  the  upper  lobe,  and  looks  like  a  tuberculous  excava- 
tion transformed  into  a  fistula ;  frequently  also,  several  continu- 
ous or  contiguous  branches,  unequally  dilated,  and  forming  by 
their  inter-communication  a  sort  of  burrow  filled  with  puriform 
mucus,  present,  at  first  sight,  the  appearance  of  an  anfractuous 
cavity  of  the  same  kind.  These  cases  may  occasion  some  diffi- 
culty, especially  to  an  inexperienced  anatomist.  In  the  chapter 
on  phthisis  I  shall  point  out  the  marks  which  will  always  dis- 
tinguish the  two  affections,  except  in  some  very  uncommon 
cases. 

The  density  and  consistence  of  the  dilated  tubes  are  extremely 
various.  Most  commonly  the  mucous  membrane  is  from  a 
quarter  to  a  third  of  a  line  in  thickness,  uneven  in  its  surface, 
softer  than  natural,  and  of  a  strong  violet  red  color,  which  is 
found  to  enter  deep  into  its  substance.  The  softness  of  the 
membrane  is  sometimes  so  great  that  we  can  separate  it  with  the 
back  or  handle  of  the  scalpel.  Outside  the  mucous  membrane 
there  is  an  envelop  nearly  of  the  same  thickness,  white  and  very 
firm,  consisting  partly  of  a  very  dense  cellular  substance  and 
partly  of  a  fibrous  tissue.  The  cartilaginous  circles  sometimes 
remain  visible,  but  never  the  yellow  muscular  apparatus  which 
distinguishes  the  sound  bronchi.  In  the  bronchial  ramifications 
of  a  smaller  order,  the  envelop  above  mentioned  has  here  and 
there  a  cartilaginous  texture  ;  but  in  this  case  it  ceases  to  retain 
its  symmetrical  form,  and  extends  in  different  points  more  or  less 
into  the  substance  of  the  lungs.  Sometimes  this  cartilaginous 
production  occupies  the  greater  part  or  the  whole  of  thespace 
contained  between  the  dilated  bronchi ;  a  remarkable  example  of 
which  will  be  noticed  at  the  end  of  this  chapter.  At  other  times 
the  dilated  bronchi  are  extremely  thin,  and  hardly  retain  any 
trace  of  their  original  structure.  In  this  state  they  are  some- 
what firmer  than  the  healthy  mucous  membrane,  very  smooth 
internally,  and  usually  red,  but  without  obvious  vascular  injec- 
tion. Sometimes  their  tenuity  is  such  that  they  may  be  com- 
pared to  the  pellicle  of  an  onion.  I  have  never  seen  the  whole 
course  of  the  bronchi  dilated  in  this  manner ;  and  the  greatest  of 
the  partial  enlargements  which  I  have  observed  might  have  con- 
tained a  walnut  without  its  shell.     These  dilated  bronchi  with 


DILATATION    OF    THE    BRONCHI.  1  17 

thin  parietes,  when  first  laid  open  by  the  scalpel,  have  a  striking 
resemblance  to  the  vesicular  lungs  of  the  class  of  animals  deno- 
minated batrachia.  This  affection  may  exist  in  any  part  of  the 
lungs,  but  is  most  common  in  the  superior  lobes.  Ordinarily  it 
exists  in  only  a  small  number  of  the  ramifications  of  the  bronchi : 
sometimes,  however,  it  extends  to  all  the  branches  of  one  of  the 
lobes.  In  this  case,  the  dilatation  is  always  greater  (not  rela- 
tively merely,  but  absolutely)  in  the  smaller  than  in  the  larger 
ramifications,  and  greater  in  these  latter  than  in  the  trunks 
whence  they  originate.  The  common  trunks  are  rarely  dilated, 
in  any  perceptible  degree,  even  in  the  cases  where  some  of  their 
branches  emulate  them  in  diameter.  When  the  dilatation  of 
the  bronchi  is  so  great  as  this,  the  intermediate  substance  of  the 
lung  is  flabby,  void  of  air,  evidently  compressed,  and,  in  short, 
resembling,  in  every  respect,  the  same  substance  when  com- 
pressed towards  the  spine,  by  an  effusion  of  serous  or  purulent 
fluid  into  the  cavity  of  the  pleura. 

When  this  lesion  is  slight,  and  affects  only  the  smaller  branches 
(in  which  it  always  commences,)  it  is  easily  mistaken  during  dis- 
section. One  thing  which  should  call  our  attention  to  it  is  the 
observation  of  a  puriform  mucus  flowing  by  drops  from  the 
smaller  bronchi,  upon  cutting  into  the  lungs.* 

Occasional  causes. — The  dilatation  of  the  bronchi  is  only  met 
with  in  cases  of  chronic  mucous  catarrh.  This  single  fact,  cou- 
pled with  what  we  know  respecting  the  long  continuance  of  mu- 
cous sputa  in  the  spot  where  they  have  been  secreted,  enables  us 
to  conceive  the  mode  in  which  the  disease  is  formed.  A  tempo- 
rary dilatation  produced  by  a  voluminous  sputum,  is  rendered 
permanent  by  the  constantly  successive  secretion  of  similar  ones. 
In  the  present  state  of  our  knowledge,  we  are  unable  to  explain 
why  the  bronchial  tunics  should  in  one  case  be  thicker  and  in 
another  thinner  than  natural,  any  more  than  we  can  explain  the 

*  Andral,  in  accordance  with  the  views  of  Laennec,  gives  the  following  sum- 
mary of  his  observations  on  this  affection.  In  some  cases,  the  texture  of  the 
bronchial  tubes  is  considerably  thickened,  the  different  anatomical  elements 
which  enter  into  their  composition  becoming  more  marked.  In  others,  the  dila- 
ted tubes  are  distinctly  atrophied,  their  whole  substance  consisting  of  a  very 
thin  membrane,  in  which  we  can  no  longer  trace  either  fibrous  or  cartilaginous 
tissue.  We  have,  therefore,  three  different  kinds  of  dilated  bronchi,  in  regard 
to  the  anatomical  constitution  of  their  tunics  : — 1.  Dilatation  with  a  natural  con- 
dition of  the  tunics;  2.  Dilatation  with  increased  thickness  of  the  tunics  ;  3. 
Dilatation  with  diminished  thickness  of  the  tunics.  (Anat.  Pathol,  p.  500.)  The 
same  author  informs  us.  that  dilatation  of  the  bronchi  maybe  produced  in  a  very 
short  time,  as  is  instanced,  he  conceives,  in  the  case  of  infants  who  had  never 
suffered  from  cough,  but  during  two  or  three  months  preceding  their  death.  In 
these  cases,  however,  M.  Guersent  is  of  opinion,  that  the  dilatation  is  often  con- 
genital ;  and  he  thinks  this  view  is  corroborated  by  the  comparatively  greater 
frequency  of  this  lesion  in  children  than  in  adults,  even  in  adults  who  have  been 
long  affected  with  habitual  and  severe  coughs.  (Diet,  de  Med.  Art.  Coqueluche, 
t.  vi.  p.  12.) — Transl. 


118  DILATATION    OF    THE    BRONCHI. 

analogous  diversity  of  volume  which  is  produced  in  the  walls  ol 
the  heart  by  the  same  mechanical  obstruction.  The  bronchial 
tubes  which  open  into  a  tuberculous  or  gangrenous  excavation, 
are  commonly  dilated,  and  continue  so  after  the  transformation 
of  the  cavity  into  a  fistula.  In  this  variety  of  dilatation,  the 
bronchi  almost  always  retain  their  cylindrical  form;  and  this 
may  perhaps  be  accounted  for  by  the  contents  of  the  excavation 
not  being  permitted  to  remain  long  in  them,  but  merely  to  tra- 
verse them  under  the  impulse  of  an  energetic  cough.  The  same 
circumstance  may  explain  the  inferior  frequency  of  occurrence, 
and  likewise  the  slighter  degree  of  dilatation,  observed  in  the 
larger  bronchi.* 

Signs  and  symptoms. — The  physical  signs  by  which  we  can 
recognise  dilatation  of  the  "bronchi,  are  pretty  numerous,  and 
vary  according  to  the  extent  of  the  affection.  When  the  whole 
of  one  lung  is  affected,  percussion  sometimes  elicits  a  duller 
sound  than  natural,  owing  no  doubt  to  the  compression  of  the 
pulmonary  substance ;  but  this  sign  is  seldom  well  marked  in 
cases  of  simple  dilatation.  Over  the  seat  of  the  principal  dilata- 
tions, pectoriloquy  more  or  less  perfect  is  perceived ;    together 

*  Andral  is  of  opinion  that  the  varieties  of  dilatation  which  are  accompanied 
by  hypertrophy  of  the  bronchial  tunics,  cannot  be  produced  in  the  mechanical 
manner  described  by  Laennec  :  the  augmentation  of  the  diameter  of  the  tubes,  he 
thinks,  must  be  explained  in  the  same  manner  as  the  augmented  thickness  of 
the  tissue,  both  being  the  result  of  a  vital  hypertrophy.  (Clin.  Med.  t.  ii.  p.  33.) 
The  following  explanation  of  the  phenomena  is  given  by  M.  Roche,  (Diet,  de 
Med.  et  de  Chir.  Prat.  Art.  Bronchite,  t.  iv.  p.  263.  Paris,  1830.)  "  We  consid- 
er inflammation  to  be  the  undoubted  cause  of  this  lesion,  and  the  following  is 
the  way  in  which  it  operates  in  producing  it.  By  diminishing  the  cohesion  of  the 
tissues  in  which  it  is  situated,  the  inflammation  of  the  bronchi  occasions  them 
to  yield  under  the  pressure  of  the  air  during  the  violent  fits  of  coughing  ;  and 
the  temporary  dilatation,  through  frequent  recurrence,  at  length  becomes 
permanent.  If  the  dilatation  is  produced  slowly,  which  is  the  most  common 
case,  the  tube  still  preserving  a  certain  degree  of  resistance,  becomes  hypertro- 
phied,  like  every  other  part  excited  to  inordinate  action.  If,  on  the  other  hand, 
the  dilatation  is  rapid,  the  tonics  are  extended  beyond  their  natural  elasticity, 
and  having  no  power  of  reaction,  become  atrophied."  This  opinion  is  par- 
tially adopted  by  Dr.  Williams,  (Cyclopaedia  of  Pract.  Med.  vol.  i.  Art.  Bronchitis, 
p.  320,)  but  he  reverses,  in  one  respect,  the  cause  and  effect  in  the  explanation 
of  M.  Roche.  "The  physical  cause  of  dilatation  of  the  bronchi,"  says  Dr.  Wil- 
liams, "is to  be  found  in  acts  of  respiration  and  cough,  exerting  a  degree  of 
pressure  on  the  softened  membrane,  greater  than  its  elacticity  can  resist.  Thus 
the  forcible  inspiration  which  succeeds  each  fit  of  coughing  acts  with  greater  ef- 
fect on  these  weaker  parts;  and,  again,  the  violent  expiration  of  conghinf  brings 
an  undue  pressure  on  the  same  tubes,  which,  distended  in  one  part,  and  partially 
obstructed  by  the  thickening  of  their  membrane  in  another,  are  perpetually  ex- 
posed to  a  straining  influence.  Induration,  the  effect  of  another  degree  of  the 
inflammatory  process,  sometimes  succeeds,  giving  the  dilated  portions  that  rigid- 
ity that  is  occasionally  noticed  in  them." 

Dilatation  of  the  bronchi  is  incidentally  represented  in  the  First  Fasciculus  of 
Dr.  Carswell's  Pathological  Anatomy,  (pi.  i.  fig.  4  ;  pi.  iv.  fig.  4,)  now  in  course 
of  publication,  and  will  be  more  completely  illustrated  in  a  future  Fasciculus  of 
this  incomparable  and  invaluable  work.  See  also  fig.  50  and  52  of  Dr.  Hope'* 
Illustrations  of  Morbid  Anatomy. —  Transl. 


DILATATION    OF    THE    BRONCHI. 


119 


with  a  large  mucous  rhonchus,  precisely  like  the  cavernous 
rhonchus  of  phthisis.  And  in  the  same  places  there  exists  the 
bronchial  respiration,  which  an  inexperienced  observer  may  very 
readily  confound  with  the  puerile,  on  account  of  the  intensity  of 
the  sound. 

The  bronchial  respiration  becomes  cavernous  over  the  site  of 
the  greatest  dilatations ;  and  in  those  nearest  the  surface  of  the 
lungs,  the  cough  and  rattle  assume  also  the  cavernous  character. 
In  the  same  points,  the  voice,  respiration,  and  cough,  frequently 
yield  the  veiled  puff,  that  is,  a  sensation  as  if  a  thin  veil  or  wet 
membrane  was  only  interposed  between  the  column  of  air  and 
the  ear,  and  vibrated  at  each  breath.* 

Sometimes  all  these  phenomena  disappear  for  a  time,  particu- 
larly if  existing  in  the  lower  parts  of  the  lungs,  owing  to  the  ac- 
cumulation of  sputa,  and  re-appear  after  a  copious  expectoration 
or  a  change  of  posture.  When  the  dilatation  exists  only  in  one 
point,  the  signs  just  mentioned  are  confined  to  that  point,  and 
are  usually  less  strongly  marked. 

If  the  dilatation  is  moderate  and  nearly  equal  in  several  of  the 
bronchi,  there  will  be  diffused  bronchophony  in  place  of  pectori- 
loquy. When  the  dilatation  is  extensive,  bronchophony  and 
bronchial  respiration  exist  over  the  whole  space  affected,  and 
perfect  pectoriloquy  in  some  points  only. 

In  cases  even  of  the  most  extensive  dilatation,  the  symptoms 
rarely  indicate  the  severity  of  the  disease.  Most  commonly 
there  is  neither  fever  (at  least  continued  fever)  nor  emaciation ; 
and  if  the  patient  is  not  obliged  to  undergo  severe  bodily  labor, 
he  is  scarcely  sensible  of  any  diminution  of  strength.  Even  the 
respiration  is  not  impeded,  except  under  the  influence  of  quick 
and  rapidly  renewed  movements.  The  expectoration  is  not  more 
characteristic.  When  the  dilatation  is  very  extensive,  it  is  ex- 
tremely copious.  It  is  always  mucous,  but  occasionally  resem- 
bles the  secretion  in  the  last  stage  of  the  acute  catarrh,  and 
sometimes  it  is  quite  puriform.  It  is  generally  without  smell, 
but  occasionally  has  the  odor  of  pus,  of  good  or  bad  character. 
The  secretion  is  sometimes  so  copious  as  to  stimulate  the  rupture 
of  a  vomica. 

From  the  above  account  of  the  symptoms,  it  will  appear  that 
dilatation  of  the  bronchi  has  many  signs  in  common  with  other 
diseases,  particularly  with  phthisis,  peripneumony,  and  gangren- 
ous excavations  in  the  lungs ;  yet  from  the  whole  view  of  these 
signs  and  symptoms,  an  experienced  practitioner  can  never  have 
any  difficulty  in  the  diagnosis.! 

• 

*  This  last  sign    may  tend  to    show  that  the    pulmonary  substance  has  not  be- 
come cartilaginous,  in  this  point  at  least,  and  perhaps  in  others. — Author. 
t  That  the  diagnosis,  however,  between  phthisis  and  dilatation  of  the  bronchi 


ISO  DILATATION    OV    THE    BRONCHI. 

Treatment. — This  affection  being  only  a  consequence  and  a 
complication  of  the  catarrh,  it  is  evident  that  the  only  means  we 
possess  of  restoring  the  bronchi  to  their  natural  size,  is  by  dimi- 
nishing the  secretion  of  the  mucous  membrane.  If  there  is  any 
case  wherein  tonics,  bitters,  aromatics,  and  the  balsams  are  bene- 
ficial, it  is  in  this ;  and  if  there  exists  at  the  same  time  a  cachec- 
tic state  of  the  system,  it  will  be  well  to  combine  with  these,  the 
preparations  of  steel  and  the  medicines  called  anti-scorbutic. 

The  dilatation  of  the  bronchi,  without  being  a  very  common 
affection,  is  however,  much  less  rare  than  I  long  conceived  it  to 
be.  It  is  not  unfrequently  met  with  in  children  after  hooping 
cough,  and  in  old  persons ;  and  within  these  last  six  years  I 
have  met  with  a  great  many  instances  of  it.  Andral  has  re- 
corded four  examples  of  this  affection,  when  existing  partially.* 
I  shall  here  give  some  account  of  two  of  these ;  and  then  subjoin 
four  others,  where  the  dilatation  was  more  general.  The  two 
first  of  these  four  cases  were  communicated  to  me  by  M.  Cayol. 
The  two  others  are  equally  remarkable  in  respect  of  their  ana- 
tomical characters  and  the  last  one  may  perhaps  be  considered  no 
less  so  on  account  of  the  exactness  with  which  the  most  minute 

is  often  a  matter  of  great  difficulty,  is  proved  by  the  inability  of  so  acute  and  ex- 
perienced an  observer  as  M.  Louis  to  distinguish  them,  in  one  case.  See  his 
Recherches,  Obs.  xi.  p.  231,  et  seq. —  Transl. 

Instead  of  becoming  dilated,  the  bronchi  may  become  contracted,  and  even 
obliterated.  In  my  Clinique  Medicate,  I  have  dwelt  particularly  upon  this  mode 
of  alteration,  which  has  also  been  studied  in  an  especial  manner  by  Dr.  Rey- 
naud — (see  Dictionnaire  de  Medicine  ou  Repertoire  gintral  de  Sciences  ^Medicates, 
art.  Broaches.)  The  contraction  of  the  bronchi  may  be  owing  to  different 
causes.  It  may  arise  from  a  simple  thickening,  either  permanent  or  temporary, 
of  the  mucous  membrane  of  these  tubes.  It  may  also  arise  from  hypertrophy 
of  the  cellular  tissue,  subjacent  to  the  membrane.  In  my  Clinique  Medicale 
(torn.  3.  p.  195.  3d  edit.),  I  have  cited  a  case  in  which  a  cartilaginous  tumor, 
developed  in  the  midst  of  the  parietes  of  one  of  the  bronchi,  had  so  much  en- 
croached upon  its  calibre,  as  to  obstruct  and  almost  completely  efface  it.  All 
tumors  developed  in  the  neighborhood  of  the  bronchi,  should  be  ranked  in  the 
number  of  those  alterations  which  often  compress  these  conduits  and  diminish 
their  calibre.  The  reader  will  find  in  my  Clinique  Medicale  many  facts  relating 
to  this  point.  The  obliteration  of  the  bronchi  is  less  common  than  their  sim- 
ple contraction.  It  is  in  their  minute  ramifications  that  it  has  been  more  par- 
ticularly noticed  :  still  it  has  also  been  observed  in  the  larger  tubes,  and  even 
in  the  main  trunk  which  transmits  the  air  to  each  lung.  In  this  last  case,  the 
tumors  developed  around  the  bronchi  cause,  by  their  gradual  growth,  the  calibre 
of  the  tubes  to  be  effaced.  Tubercles  developed  in  the  lungs  may  compress 
and  close  some  portion  of  the  bronchial  tubes.  In  some  instances,  the  air-tubes 
become  changed  into  a  species  of  fibrous  cords,  independently  of  any  compress- 
ing cause. 

The  size  and  number  of  bronchi  either  contracted  or  obliterated,  give  rise  to 
a  corresponding  variety  of  symptoms,  which  differ  in  intensity  at  least,  if  not 
in  their  nature.  A  dyspnoea  will  be  observed  corresponding  in  intensity  with 
the  seat  and  extent  of  contraction  or  obliteration.  In  a  case  reported  by  me  in 
which  the  principal  air  tube  of  on#of  the  lungs  was  greatly  compressed  by  a 
tumor,  no  sound  could  be  heard  in  this  lung  except  a  respiratory  murmur,  vastly 
more  feeble  than  that  of  the  other  lung. — Andral. 

t  Op.  Cit.  Obs.  v.  vi.  viii.  ix. 


DILATATION    OF    THE    BRONCHI.  121 

circumstances  of  the  state  of  the  lungs  were  indicated  by  the  steth- 
oscope. M.  Andral's  first  patient  (obs.  vi.)  died  of  diseased  heart. 
In  this  case  there  had  existed,  under  the  right  clavicle  and  in  the 
subspinal  fossa  of  the  same  side,  a  diffuse  bronchophony  and  a 
bronchial  and  puffing  respiration.  The  bronchial  ramifications  of 
the  upper  lobe  on  this  side,  were  found  manifestly  dilated,  not 
altered  in  shape,  but  with  thickening  of  their  parietes.  In  this 
case,  the  branches  of  a  lesser  order  exhibited  as  distinct  circular 
cartilages  as  at  the  bifurcation  of  the  trachea.  The  second  case 
(obs.  viii.)  was  that  of  a  man  forty-six  years  old,  who  died  with 
general  symptoms  of  phthisis.  The  expectoration  was  puriform  ; 
the  voice  resounded  strongly  over  the  whole  left  side  ;  and  a  little 
above  the  lower  angle  of  the  scapula,  there  was  distinct  pectoril- 
oquy. On  examination  after  death,  there  was  found  in  the  cor- 
responding point  of  the  lung  a  dilatation  of  one  of  the  bronchi,  of 
the  size  of  a  walnut ;  and  in  the  same  lung  several  other  bronchi 
were  dilated  partially  in  different  successive  points,  to  tripple  or 
quadruple  their  natural  size.  The  intermediate  substance  of  the 
lung  was  flabby  and  compressed. 

Case  I.  Acute  dilatation  of  the  bronchi  after  hooping-cough. — 
A  child,  three  and  a  half  years  old,  and  affected  with  hooping 
cough  for  three  months,  came  into  the  Hopital  des  Enfans,  in 
January,  1808.  The  cough  returned  in  fits  after  an  interval  of 
several  hours,  and  was  followed  by  a  copious  expectoration  of  a 
yellow,  very  fetid,  puriform  fluid.  This  fluid  which  smelt  like 
the  puss  from  an  abscess,  was  brought  up  by  mouthfuls  rather  than 
by  the  usual  process  of  expectoration.  The  child  always  lay  on 
the  left  side,  which  was  found  to  yield  a  dull  sound  on  percussion. 
In  the  intervals  of  the  cough  it  slept  well,  and  seemed  to  feel  no 
pain.     It  died  about  a  fortnight  after  its  admission. 

Dissection  thirty-six  hours  after  death. — The  left  lung  was 
sound  in  the  upper  parts,  but  the  inferior  lobe  was  hard,  heavy, 
livid,  and  slightly  adherent  to  the  costal  pleura.  On  cutting  into 
it,  an  ounce  and  a  half  of  fetid  pus,  exactly  like  what  had  been  ex- 
pectorated, made  its  escape  from  a  multitude  of  round,  smooth 
cavities,  varying  in  size  from  that  of  a  large  pea  to  that  of  a  finger- 
end.  On  further  examination  it  was  found  that  these  cavities 
were  connected  with,  and  were  in  fact  mere  dilatations  of  the  bron- 
chi. Each  bronchial  branch,  after  running  about  half-an  inch  into 
the  lung,  became  gradually  enlarged,  and  finally  terminated  in  a 
cul-de-sac,  constituting  one  of  the  cavities  above  mentioned.  To- 
wards their  termination,  most  of  these  dilated  tubes  would  have 
admitted  the  little  finger  ;  and  the  smaller  ones  would  have  con- 
tained an  ordinary  quill.  In  their  course  they  gave  off  branches, 
which,  after  running,  at  most,  two  inches,  terminated  in  similar 
culs-de-sac.  The  mucous  membrane  lining  these  tubes  was 
16 


122  DILATATION    OF    THE    BRONCHI. 

throughout  of  a  deep  livid  red.  It  was  thinner  than  natural,  but 
was  not  in  the  slightest  degree  ulcerated.  These  dilated  tubes 
were  so  numerous  that  an  incision  could  not  be  made  without  di- 
viding many  of  them :  they  constituted  at  least  three-fourths  of 
the  volume  of  this  part  of  the  lung.  The  intermediate  substance 
was  of  a  greyish  color,  compact  but  flabby,  and  retained  no  trace 
of  its  natural  cellular  structure.  The  right  lung  was  sound.  The 
mucous  membrane  of  the  trachea  was  of  a  livid  red,  particularly 
at  its  lower  extremity  ;  while  that  of  the  larynx,  on  the  contrary, 
was  very  pale.  The  liver  was  very  large,  yellowish,  soft,  and  fatty. 
The  other  viscera  were  sound.* 

Case  II.  Chronic  dilatation  of  the  bronchi. — Miss  M.,  aged 
seventy-two,  affected  upwards  of  fifty  years  with  a  complaint  which 
presented  most  of  the  symptoms  of  phthisis,,  viz.  frequent  haemop- 
tysis, habitual  cough  with  expectoration  of  opaque,  yellow  sputa, 
(having  at  one  time  the  characters  of  pus,  and  at  others  those  of 
puriform  mucus,)  and  short  and  oppressed  breathing.  These 
symptoms  varied  much,  having  decided  remissions,  but  hardly  ever 
a  distinct  intermission.  However,  she  was  always  able  to  attend 
to  her  affairs,  and  indeed  never  considered  herself  as  sick.  On 
her  admission  to  the  hospital,  although  broken  down  with  years, 
she  did  not  appear  very  ill,  and  exhibited  merely  her  habitual 
toms,  with  the  addition  of  a  slight  diarrhoea  and  some  oedema 
of  the  legs.  This  latter  symptom,  however,  progressively  increas- 
ed, with  great  increase  of  the  dyspnoea,  and  she  sunk  apparently 
more  from  the  dropsical  affection  than  from  the  original  disease. 

Dissection  forty-four  hours  after  death. — The  lungs  were  at- 
tached to  the  ribs  and  the  mediastinum  by  ancient  and  lax 
cellular  adhesions.  The  substance  of  the  lungs  was  soft  and 
unelastic,  and,  on  compressing  them  between  the  fingers,  hard 
portions  of  various  size  were  felt,  especially  in  the  right  superior 
lobe.  On  cutting  into  this  lobe,  a  great  many  rounded  cavities 
were  found,  smooth,  and  of  reddish  color  internally,  some  of 
which  were  empty,  and  others  containing  a  fluid  like  that  expec- 
torated by  the  patient.  These  cavities  were  of  very  unequal 
size,  the  largest  being  capable  of  admitting  the  end  of  the  thumb. 
They  were  separated  from  one  another  by  partitions  of  a  pretty 
firm  consistence,  composed  of  the  condensed  pulmonary  tissue. 
On  further  examination,  they  were  found  all  to  communicate 
with  the  bronchi,  of  which  they  were  evidently  continuations. 
These  tubes,  a  short  distance  from  their  origin,  and  just  where 
they  cease  to  be  cartilaginous,  were  found  to  be  considerably 
dilated,  and  to  retain  this  increased  diameter,  or  to  become  pro- 

*  This  case  is  considerably  abridged;  but  nothing  is  omitted  directly  bearing 
on  the  subject  of  this  work.  Most  of  the  subsequent  cases  will  be  treated  in 
the  same  way. — Transl. 


DILATATION    OF    THE    BRONCHL  123 

gressively  larger,  to  the  point  of  their  termination  near  the  sur- 
face of  the  lung.  In  their  course  they  gave  off  branches,  some 
of  which  were  dilated  and  others  not.  The  dilated  portions  ex- 
hibited here  and  there  small  cartilaginous  or  bony  points,  par- 
ticularly at  the  origin  of  the  collateral  ramifications.  In  these 
diseased  bronchi  it  was  impossible  to  trace  the  different  layers  of 
membrane ;  they  appeared  to  consist  of  one  only,  which  could 
not  be  separated  from  the  substance  of  the  lungs,  and  which  was 
much  harder  and  smoother  than  that  which  naturally  exists  in 
the  branches  which  are  deprived  of  cartilages.  There  was  not 
the  slightest  mark  of  ulceration.  Almost  all  the  bronchi  of  the 
right  superior  lobe  were  in  the  state  just  described.  The  largest 
might  be  seven  or  eight  times  their  natural  size,  while  some  were 
much  less  dilated,  and  others  hardly  at  all.  The  whole  of  the 
space  occupied  by  the  hollows  of  these  dilated  branches  was 
about  three-fourths  that  of  the  whole  superior  lobe.  Some  of  the 
cavities  were  only  separated  from  each  other  by  very  thin  par- 
titions, consisting  of  the  pulmonary  tissue  condensed  into  the 
state  of  membrane.  In  the  middle  and  inferior  lobes  of  the 
same  side  there  were  only  a  few  of  the  bronchi  slightly  dilated. 
In  the  left  superior  lobe,  two  or  three  of  them  were  considerably 
dilated,  but  not  so  as  to  form  cavities  like  those  on  the  opposite 
side  ;  in  the  left  inferior  lobe  there  was  no  dilatation.  The  mu- 
cous membrane  of  the  larynx  and  trachea  was  sound. 

Case  III.  General  dilatation  of  the  bronchi  of  one  lung. 
Conversion  of  the  pulmonary  substance  into  fibro-cartilage. — A 
patient  came  into  the  Hospital  Necker,  in  the  winter  of  1821-2, 
who  had  been  affected  with  cough  and  copious  muco-purulent 
expectoration  ever  since  an  attack  of  pleuro-peripneumony  twenty 
years  before  :  he  had  oppressed  breathing  :  and  on  the  left  side 
of  the  chest,  which  was  one-third  smaller  than  the  right,  there 
was  well-marked  bronchophony  around  the  lower  angle  of  the 
scapula.  This  man  died  suddenly,  with  symptoms  of  apoplexy, 
after  being  only  a.  few  hours  in  the  hospital. 

On  examination,  the  left  lung  was  found  reduced  to  the  size 
of  the  two  fists,  and  every  where  closely  united  with  the  costal 
pleura,  by  means  of  a  nbro-cartilaginous  membrane,  except  op- 
posite the  scapula,  where  it  was  distant  from  it  an  inch,  being  in 
this  point  connected  by  sero-fibrous  adhesions  of  this  length. 
This  space  also  contained  about  three  ounces  of  a  bloody  serosity. 
The  whole  of  this  lung  was  converted  into  a  substance  in  appear- 
ance and  consistence  intermediate  between  cartilage  and  fibrous 
membrane.  The  two  lobes,  though  intimately  united,  were  still 
very  distinguishable. one  from  another,  the  upper  being  of  a  uni- 
form slate-grey  color,  and  the  other  as  white  as  tendon.  When 
cut  io  thin   slices,  this  substance   was  slightly   transparent,  and 


124  DILATATION    OF    THE    BRONCHI. 

had  nothing  of  the  flaccidity  of  a  lung  simply  deprived  of  air  by 
compression.  The  bronchial  .tubes  were  in  general  dilated,  the 
diameter -of  the  latter  divisions  being  only  two  or  three  lines  less 
than  that  of  the  first :  they  terminated  in  culs-de-sac.  The 
greater  number  of  these  branches  contained  a  yellowish,  opaque 
matter,  in  appearance  intermediate  between  opaque  mucous  sputa 
and  very  soft  cheese.  Intermixed  with  this,  there  was  a  whiter 
chalky  matter  which  resisted  the  scalpel.  The  mucous  mem- 
brane of  almost  all  these  tubes,  was  of  the  color  of  the  lees  of 
red  wine,  and  slightly  thickened.  The  smaller  bronchial  branches 
were  obliterated  and  lost  in  the  general  semi-cartilaginous  mass 
into  which  the  substance  of  the  lung  was  converted.  There  was 
no  sign  of  tubercles.     The  right  lung  was  quite  sound. 

Case  IV.  Chronic  dilatation  of  the  bronchi.  Acute  double 
peripneumony. — A  coachman,  aged  forty-one,  was  received  into 
the  clinical  wards  of  the  Faculte,  27th  March,  1825.  From 
infancy  he  had  been  subject  to  a  cough  attended  by  an  expecto- 
ration of  a  yellowish  or  greyish  color,  but  which  had  not  in  any 
way  prevented  him  from  following  his  occupation.  During  the 
last  six  months,  however,  his  complaints  had  increased ;  the 
cough  had  all  at  once  became  very  frequent,  and  the  expectora- 
tion of  thick,  yellow  opaque,  and  fetid  matter,  very  copious. 
At  the  same  time,  there  was  also  present,  a  slight  irregular  fever, 
night  sweats,  diarrhoea,  emaciation,  and  increasing  weakness ; 
and  six  weeks  before  his  admission  he  had  had  two  severe  attacks 
of  haemoptysis.  He  had  suffered  from  pain  in  the  right  side,  but 
never  in  the  left.  The  only  remedy  to  which  he  had  had  re- 
course during  his  illness,  was  a  pectoral  ptisan  ;  and  he  had  fol- 
lowed his  business  to  within. a  few  days  of  his  admission  into  the 
hospital.  At  this  time  his  state  was  as  follows :  emaciation  in- 
considerable, skin  slightly  yellow  ;  pulse  frequent,  full,  but  not 
strong;  cough  frequent,  expectoration  thick,  yellow,  opaque, 
and  somewhat  fetid ;  no  dyspnoea  ;  appetite  moderate,  and  no 
disorder  of  the  digestive  functions.  The  chest  sounded  pretty 
well  on  the  right  side,  much  less  so  on  the  left,  especially  in  the 
lower  part,  which  was  evidently  contracted.  The  respiration 
was  good  on  the  right  side ;  but  on  the  left,  it  was  hardly  per- 
ceptible laterally  and  behind,  and  was  there  accompanied  by  an 
obscure  mucous  rhonchus.  On  the  upper  parts  of  the  same  side, 
both  before  and  behind,  the  respiration  was  replaced  by  a  very 
distinct  cavernous  rhonchus ;  and  about  the  lower  angle  of  the 
scapula,  there  was  a  very  strong  mucous  rhonchus.  Over  the 
whole  of  the  left  scapula  there  was  imperfect  pectoriloquy. 
From  these  signs  I  deduced  the  following  diagnosis : Excava- 
tion in  the  superior  part  of  the  left  lung ;  contraction  of  the 
same  side  from  an  ancient  pleurisy.     I  left  in  doubt,  for  the  time, 


DILATATION    OF    THE    BRONCHI.  125 

tho  question  as  to  the  nature  of  the  excavation ;  the  probabilities 
seeming  nearly  equally  in  favor  of  its  being  the  result  of  soft- 
ened tubercles,  and  of  a  gangrenous  eschar.  (Pectoral  infusion 
with  two  drams  of  lime  water, — draught,  with  at  her  and  half  a 
dram,  of  extract  of  bark.) 

In  the    beginning  of  April  he   was   better :    the  fever  less,  the 
complexion   and    ap;  etite  good.     Percussion  of  the  left   chest  a 
little  above  the  nipple,  produced  a  distinct  guggling,  with  a  sen- 
sation of  vibration  and  a  circumscribed  hollow   resonance,  indi- 
cating, in  this   point,  a  cavity,  with   flexible  and  somewhat  elastic 
walls,  and    containing   a  half-liquid    matter.     Every  blow   given, 
while  the  patient  was  speaking,    produced  a  very  marked  catch 
or  stammer  in  the  voice.     April  10.  Expectoration  more  copious, 
puriform  and    fetid ;  breath    very    offensive ;  hardly    any   fever ; 
appetite  middling.     A  more    complete    exploration  of    the  chest 
gave  the    following  results :    On  the  left  chest,  distinct  pectori- 
loquy from  the  clavicle  as  low  as   the  third  and    fourth  ribs  ante- 
riorly ;  on  the  side,  from  the  axilla  to  the  fifth  rib ;  and  behind, 
from  the  top  of  the  shoulder  to  the  lower  angle  of  the  scapula  and 
below.      When  the  patient  lay  on   the  right  side,  pectoriloquy 
was  also  very  evident  on  the  lower  parts  of  the  left  side,  both 
posteriorly    and  laterally,  which  was  not  the  case  when   in   the 
sitting  posture.     A  cavernous  rhonchus,  still  more   distinct  than 
the  pectoriloquy,  existed  in  the  same  points.     These  signs  allow- 
ing only  two  suppositions,  namely,  a  general  and  very  consider- 
able dilatation  of  the  bronchi,  or  an  anfractuous  or  multi-locular 
tuberculous  excavation,  extending  over   nearly  the  whole  of  the 
left  lung,  I  gave    my  opinion  in  favor  of  the  first,  from   consider- 
ing the  general    condition  of  the  patient  and    the  progress  of  the 
disease ;    still,  however,    leaving  in    doubt  the   co-eXistence   of  a 
gangrenous  eschar  in  the  lung.     18th.  Considerable  increase  of 
fever  during  the  two  last  days ;  cough  more  frequent,  particularly 
at  night ;    expectoration  more  copious,  greyish  and  very   fetid  ; 
return  of  the  diarrhoea ;  loss  of  appetite.     (Same  prescription. 
Half  a  dram  of  diascordium*  twice  a  day.)     22nd.  Increase  of 
all  the    symptoms ;  high    fever ;    cough  frequent ;    expectoration 
puriform,   coherent,  of  an  ash-grey  color,  and  still  more  offen- 
sive than  usual,  prostration  of  strength  ;  tracheal  rhonchus.     On 
the  right  side  the  chest  sounded  well ;  the  respiration  was  strong> 
and  accompanied  by  a  deep  sonorous  rhonchus,  anteriorly   and 
laterally ;  while   posteriorly,  it    was   bronchial,  and   accompanied 
in  some  places  by  a  strong  mucous  rhonchus.     There  was  also  a 
slight  crepitous  rhonchus  on   the  right  side,  about  the  anterior 

A  \  ery  complex  electuary  of  an  astringent  and  narcotic  quality  invented  by 
Fracastorius.     It   is  named  from   the  plant   Scordium  (S.  Teucrium,   Linn.)  the    - 
Jeaves  of  fthich  form  one  of  its  ingredients. —  Transl. 


•  126  DILATATION    OF    THE    BRONCHI. 

part  of  the  sixth  rib,  and  towards  the  roots  of  the  lung,  in  which 
points  the  respiration  was  bronchia] ;  and  also  a  similar  rhonchns 
at  the  roots  of  the  left  lung.  Over  the  whole  of  the  trachea  there 
was  a  deep  sonorous  rhonchus.  From  these  signs  I  announced 
the  existence  of  a  central  pneumonia  (i.  e.  not  having  yet  reached 
the  surface  of  the  lung)  on  the  right  side,  and  also  an  incipient 
inflammation  of  the  left  lung,  although  its  texture  was  com- 
pressed by  the  dilated  bronchi.  (Three  glasses  of  emulsion 
with  six  grains  of  tatar  emetic, — white  decoction* — half  a  dram 
of  diascordium,  ter.)  23d.  Respiration  still  bronchial  at  the 
root  of  the  right  lung ;  crepitous  rhonchus  barely  perceptible  at 
the  inner  edge  of  the  scapula :  chest  still  yielding  a  good  sound 
on  the  right  side.     He  died  next  day.-f 

Dissection  thirty-eight  hours  after  death. — The  right  lung 
was  large  and  heavy,  and  scatjtoely  collapsed  at  all  on  the  thorax 
being  laid  open.  Upon  cutting* into  it,  its  texture  was  found,  in 
general,  pretty  sound,  but  containing  a  great  many  small  por- 
tions, of  a  more  or  less  deep  redi;  color,  almost  all  unconnected 
with  each  other,  of  irregular  form,  dense,  compact,  exhibiting  a 
granular  surface,  when  incised,  and  yielding,  upon  the  slightest 
pressure,  a  fluid  of  a  tawny  yellow  color,  resembling  meat-soup. 
These  portions  were  indurated  in  different  degrees ;  the  pul- 
monary substance  of  some  of  them  being  still  crepitous,  either  at 
their  exterior,  or  over  the  fourth,  third,  or  even  half  of  their 
extent.  Their  color  was  equally  various: — the  greater  num- 
ber and  the  hardest  were  of  a  deep  red,  approaching  to  violet; 
some  were  of  a  greyish  or  yellowish  red,  or  with  a  tinge  of  violet, 
less  dense,  and  less  granular ;  while  others  (and  these  were  the 
smallest  number)  were  softer,  of  an  ash-grey,  and  very  slightly 
semi-transparent.  In  these  last,  the  incised  surfaces  presented 
scarcely  any  granular  appearance,  and  exhibited,  in  different 
points,  the  healthy  cellular  texture  of  the  lungs.  These  diverse 
shades  of  induration  were  sometimes  re-united  in  the  same  dis- 
eased portion,  each  of  which  gradually  passed  into  the  natural 
structure  of  the  viscus.  The  indurated  lobules  formed  slight 
prominences  on  the  surface  of  the  lungs,  and  felt  to  the  touch 
like  accidental  productions  contained  within  their  substance. 
They  were  very  numerous  and  small  in  the  upper  lobe ;  less 
numerous,  larger,  and  more  distant  in  the  lower  ;  and  still  larger 
and  much  closer  to  one  another  in  the  middle  lobe.  In  this 
latter,  they  formed,  by  their  juxtaposition  towards  the  roots  of 
the   bronchi,   a  compact  mass   nearly  two  inches  in   diameter. 

*  A  watery  decoction  of  hartshorn  shavings  and  bread,  with  syrup. Traitsl. 

t  This  case  was  witnessed  by  Barry,  Crawford,  Carswell,  Gregory  (son  ol 
the  celebrated  professor  at  Edinburgh),  and  Townsend,  English  medical  "cntlc- 
men,  besides  many  others,  foreigners  as  well  as  French.—  Author.      . 


DILATATION    OF    THE    BRONCHI.  •  127 

Near  this  and  posteriorly,  there  was  a  small   excavation  entirely 
rilled    with  a    dirty,  black,  and   extremely  fetid    matter.      The 
walls  of  this  excavation   were  not  lined  by  any  false  membrane, 
but  consisted  of  condensed  pulmonary  substance   of  a   blackish 
color   which  became   gradually  more    dense  as  it   receded    from 
the  cavity.     This  was   evidently  a  gangrenous  eschar.     In   the 
vicinity  of  this,  and    near  the  surface  of   the  lung,  were  two  or 
three  bronchi  dilated  to  the'  size  of  a  goose-quill ;  and  traversing 
the  compact  mass  above  mentioned,  were  several  others  of  a  still 
larger  diameter,  and   terminating  in  culs-de-sac  sufficiently  large 
to  contain  a  pea.     The  inner  membrane  of  all  these  bronchi  was 
smooth  and  of  a  deep  violet-red  color.     There  was  not  a  tubercle 
in  the  whole  lung.     The  left   lung  was  much  smaller  than  the 
right,  heavy,  flaccid,  and  very  little  crepitous.      Upon  cutting 
into  it,  a  great  number  of  ovoid  cavities  presented  themselves, 
which  were  either  empty,  or  contained  a  small  quantity  of  a  dirty 
blackish  or  yellowish-red  matter,  like  pus  mixed  with  blood,  and 
of  a  fetor  approaching  that  of   gangrene.     These  cavities  were 
lined   by  the  bronchial  mucous  membrane,  which  was  of  a  very 
deep   livid   color   and   smooth,   though    puffy   and   softer   than 
natural.     They  were  of  a  very  different  size  in  different  portions 
of  the  lung.     In  the  lower  lobe,  they  were  very  numerous,  closely 
approximated,  and  almost  all  capable  of  holding  an  almond  with 
its  shell ;  while  in   the  upper,  they  were  much  smaller  and  much 
more  distant  from  each  other.     They  all  communicated  with  the 
bronchi,   and,  in  fact,  were  found  on  minute  inspection,   to  be 
the  continuation  and  termination  of  these,  dilated  in  this  extraor- 
dinary manner.     The  whole  of  these  cavities  taken  together  were 
nearly  equal  in  size  to  one  half  the  lung.     It  will  be   observed 
that  they  were  the  most  numerous  exactly  in  the  points  where 
pectoriloquy  had  existed  during  life.     In   the  lower  lobe,  they 
were  so  close  to  one  another  as  to  leave  between,  only  very  thin 
partitions  of  condensed  and  firm  pulmonary  substance.     In  the 
upper  lobe,  there  were  some  red  and  solid  portions   like  those 
described    in  the  right   lung.     The  walls    of    the    culs-de-sac 
formed  by  the  dilated  bronchi,  were  as  thick  as  those  of  the 
larger  branches,  and  this  thickening  was  caused  partly  by  the 
thickened   mucous    membrane,  and    partly  by  the    fibro-cellular 
envelop  of  the  bronchi  become  more  solid,  and  in  many   places 
cartilaginous.     In  some  places  the  partition  between  two  of  these 
dilated  bronchi  was  become  wholly  cartilaginous,  and  formed  one 
mass  with   the  degenerated   envelopes.     Besides  these  cavities, 
there  existed  another  small  one,  of  a  very  different  character,#iear 
the  origin  of  the  bronchi.     It  contained  a  small  quantity  of  a 
pulpy  matter,  of  a  decidedly  gangrenous  fetor.     It  did  not  seem 


128  .  croup. 

to  have  any  communication  with  the  bronchi,  but  appeared  to  be 
the  result  of  the  gangrene  of  one  of  the  bronchial  glands. 

After  the  examination  I  placed  the  lungs  in  water  with  a  view 
to  their  inspection  on  the  following  day.  On  looking  at  them 
twenty-four  hours  afterwards,  I  found  that  the  maceration  had 
whitened  the  incised  surfaces  in  contact  with  the  water  ;  and  I 
found,  moreover,  that  in  three  or  four  of  the  dilated  bronchi, 
which  had  not  been  opened,  and  to  which  the  water  had  not  pen- 
etrated, the  mucous  membrane  was  greatly  altered,  having  be- 
come soft,  of  a  reddish,  greenish  or  blackish  color,  and  exhaling 
a  decidedly  gangrenous  fetor.* 


CHAPTER  III.    • 

OF    CROUP,    OR    PLASTIC    INFLAMMATION    OF    THE    AIR    PASSAGES. 

Croup  has  not  been  well  understood  very  many  years.  It  ap- 
pears to  have  been  unknown  to  the  Greek  and  Arabian  phy- 
sicians ;  a  circumstance  less  to  be  wondered  at,  as  it  must  have 
been  of  rare  occurrence  in  the  very  temperate  or  warm  climates 
which  they  inhabited-!     Ballonius  (Baillou)  was  the  first  who 

*  This  circumstance  points  out  the  necessity  of  pathological  anatomists  being 
on  their  guard  against  changes  that  may  take  place  after  death.  It  seems  cer- 
tain that  those  bronchi  found  in  a  state  of  decomposition  resembling  gangrene 
on  the  second  day  of  examination,  were  not  so  on  the  first,  if  we  may  be  al- 
lowed to  judge  from  the  state  of  the  trunks  of  these  which  were  seen  in  the 
same  condition  as  those  which  had  been  laid  open.  If,  then,  any  thing  had  re- 
tarded the  examination  of  the  body  for  twenty-four  hours,  we  should  have  no 
doubt  imagined  that  the  patient  had  died  of  an  universal  gangrene  of  the  mu- 
cous lining  of  the  bronchi.  It  seems  even  probable,  that  the  partial  inflamma- 
tory indurations  would,  in  this  case,  have  assumed  a  gangrenous  appearance. 
— Author. 

t  For  a  complete  bibliographical  history  of  croup,  I  refer  the  reader  to  the 
treatise  of  Michaelis  "  De  Angina  Polyppsa '.;"  Professor  Rubini's  "  Rifiessioni 
sulla  malattia  communemamente  denominata  Crup,"  Parma  1813;  and  to  the 
recent  treatise  of  Dr.  Bretonneau,  "  De  la  Diphtherite  on  Inflammation  pellicu- 
lairc,''  Paris  1826.  All  of"  these  authors  prove  by  extracts  from  the  writings  of 
the  ancient  physicians,  that  the  croup  was  known  to  several  of  them,  particu- 
larly to  Hippocrates  unci  Aretaeus;  although  its  precise  anatomical  characters 
were  not,  owing  to  the  imperfect  state  of  pathological  anatomy  in  those  ages. 
The  description  of  Aretaeus,  in  particular,  (Lib.  i.  c.  <).)  is  conclusive  evidence, 
although,  like  so  many  others,  he  had  confounded  the  term  croup  with  the 
diphtherite  of  Bretonneau,  or  crusty  pharyngitis.  That  the  mildness  of  the 
climates  inhabited  by  the  ancient  physicians  by  no  means  afforded  an  immunity 
from  diseases  of  this  kind,  we  have  the  testimony  of  modern  writers  on  the 
diseases  of  temperate  and  warm  climates.  Among  others,  see. Hillary  on  the 
diseases  of  Barbadoes  (second  ed.  p.  134)  for  an  account  of  a  severe  epidemical 
bronchitis  in  the  year  1758,  which  was  certainly,  if  not  croup,  nearly  allied  to 
it.     "I  have  no  doubt  (says  Dr.  Cullcn— Thomson's  edit.   vol.  ii.  p.  41)  of  its 


CROUP. 


129 


noticed  this  disease  in  1756,*  although  there  can  be  little  doubt 
that  the  disease  must  have  existed  before  that  time.  The  imper- 
fect state  of  morbid  anatomy,  and  the  great  infrequency  of  cases 
wherein  the  expectoration  of  the  croupy  or  false  membrane  strik-  ♦ 
ingly  and  at  once  characterises  the  affection,  had  no  doubt  pre- 
vented this  disease  from  being  distinguished  from  many  others  of 
the  larynx  and  lungs.  Even  in  much  later  times  these  diseases 
were  confounded  or  mistaken  ;  and  it  is  evident,  that  the  dis- 
charge of  the  pretended  inner  membranes  of  the  bronchi,  and  of 
the  veins  and  arteries  of  the  lungs,  described  by  Tulpius,f  and 
other  observers  of  the  seventeenth  century ,%  were  cases  of  croup. 
The  first  good  description  which  we  have  of  this  disease  we  owe 
to  Ghisi,  a  physician  of  Cremona,  about  the  middle  of  the  last 
century.*§>  Shortly  after,  the  Scotch  and  English  physicians|| 
paid  much  attention  to  the  subject,  and  were  soon  followed  by 
the  Germans  and  French.  Quite  recently  Dr.  Bretonneau,  of 
Tours,  has  made  us  more  fully  acquainted  with  the  disease,  than 
any  previous  inquirer.^! 

Anatomical  characters. — Croup  is  an  inflammation  of  the 
mucous  membrane  of  the  air  passages,  with  exudation  of  plastic 
pus,  (coagulable  lymph,)  which,  becoming  concrete  at  the  very 
moment  of  its  formation,  lines  the  inner  surface  of  this  membrane 
to  a  greater  or  less  extent.  When  this  false  membrane  is  re- 
moved, the  subjacent  tunic  is  found  of  a  deep  vivid  red  color, 
occasionally  livid,  and  somewhat  thickened.  This  color  is  com- 
monly very  uniform  over  the  whole  space  covered  by  the  false 
• 

being  a  very  universal  disease,  with  regard  to  place  and  country  :  but  we  can 
easily  account  for  its  not  being  much  noticed,  as  it  is  a  disease  which  occurs  in 
infants  who  cannot  explain  their  feelings,  and  as  it  proves  suddenly  fatal,  leav- 
ing less  time  for  calling  the  physician  to  observe  it.  And  considering  how 
lately  it  has  been  common  to  examine  disease  by  dissection,  we  can  easily  per- 
ceive why,  for  so  long  a  time,  this  affection  has  passed  on  entirely  unobserved." 
Transl. 

*  Opera,  torn.  I.  Epidem.  et  Ephimer.  lib.  ii.  Constit.  Hiemal.  ann.  1576,  in 
annotat. — Author.  It  appears,  however,  that  Ballonius  has  little  claim  to  be 
considered  as  the  first  observer  of  the  peculiar  characters  of  croup,  although  it 
is  certainly  in  his  works  that  the  existence  of  the  false  membrane  is  first  dis- 
tinctly recorded.  From  his  own  account,  it  is  clear  that  he  learned  the  fact  of 
the  false  membrane  being  found,  from  another  person  :  "  chirurgus  affirmavit  se 
secuisse  cadaver  pueri,"  &c.  See  Ballon.  Op.  Om.  Med.  Venet.  1734,  torn.  i. 
p.  139.  See  also  Rubini's  remarks  on  this  passage — Riflessioni,p.  200,  et  seq. — 
Transl. 

t  N.  Tulpius's  Obs.  Leida?,  1641,  obs.  ix.  xii.  et  xiii. 

t  Collect.  Acad.  torn.  vii.  p.  394.  Several  of  tha  cases  referred  to  were,  how- 
ever, fibrinous  concretions  formed  in  the  bronchi  during  haemoptysis. — Transl. 

§  Martin.  Ghisi,  Lettre  Mediche.     Cremona,  1749. 

||  Dr.  Home's  "  Inquiry,"  which  is  the  first  systematic  account  of  croup  in 
I  his  country,  was  published  in  1765  :  but  the  disease  had  been  previously  notic- 
ed under  the  same  name  by  Dr.  Patrick  Blair,  in  his  Observations  on  the  Prac- 
tict  of  I'lujsir,  published  in  1718. —  Transl. 

TI  See  his  work  Sur  la  Dipthiherite,  which  has  been  published  since  our  au- 
thor's treatise  went  to  the  press. —  Transl. 

17 


130  •  croup. 

membrane,  but  is  also  not  unfrequently  unequal,  and  occasionally 
is  even  altogether  wanting.*  In  the  greater  number  of  cases,  the 
degree  of  redness  and  swelling  is  less  than  in  many  instances  of 
•the  dry  catarrh.  We  cannot,  therefore,  attribute  the  plasticity 
of  the  pus  in  croup,  the  distinctive  feature  between  it  and  the 
mucous  catarrh,  to  a  higher  degree  of  inflammation  simply. 
Besides,  we  see  frequent  examples  of  chronic  plastic  inflamma- 
tions of  the  mucous  coat  of  the  intestines  and  bladder,  with 
hardly  any  pain,  or  other  particular  symptom.  And  I  have 
myself  seen  a  case  of  chronic  croup  of  the  same  sort,  which  was 
confined  to  the  larynx,  and  supervened  during  the  suppuration 
of  a  scrofulous  tumor  of  the  thyroid  gland :  here,  after  a  cough, 
almost  dry,  of  more  than  two  months'  standing,  and  attended  by 
hardly  any  other  symptom,  the  false  membrane  was  expectorated, 
without  any  previous  indications  of  its  presence  in  the  larynx. 
The  false  membrane  which  so  frequently  forms  on  blisters  is,  of 
itself,  sufficient  to  prove  that  it  is  much  less  to  the  degree  than 
to  the  nature  of  the  inflammation,  that  we  are  to  attribute  this 
concretion  or  coagulation  of  pus  in  certain  cases.  Indeed,  the 
cause  of  it  is  much  more  probably  to  be  attributed  to  some 
peculiar  disposition  of  the  fluids,  than  to  any  affection  of  the 
solids. 

The  false  membrane  of  croup  corresponds  exactly  with  the 
form  of  the  canals  which  it  covers.  Its  thickness  is  usually 
somewhat  greater  in  the  larynx  and  trachea  than  in  the  bronchi, 
and  varies  from  less  than  half  a  line  to  a  line.  Its  consistence  is 
about  that  of  boiled  white  of  egg;  ljut  this  usually  diminishes 
towards  its  extremities,  so  that  it  becomes  sometimes,  in  this  situ- 
ation, scarcely  more  solid  than  the  thick  phlegm  of  catarrh.  It 
is  of  a  white  color,  with  sometimes  a  shade  of  yellow,  and  is  al- 
most entirely  opaque. 

Some  days,  or  even  hours,  after  its  formation,  the  false  mem- 
brane begins  gradually  to  be  detached  from  the  mucous  coat  to 
which  it  had  been  closely  adherent,  and  after  being  broken  into 
fragments  by  the  cough,  is  sometimes  expectorated.  The  sepa- 
ration is  effected  by  a  more  liquid  secretion,  which,  becoming  in 
its  turn  also  concrete,  constitutes  a  second  false  membrane.  This 
process  may  be  repeated  several  times  in  succession  ;  but  in 
general  each  successive  formation  is  less  consistent  than  the  pre- 
ceding. The  croupy  .membrane,  properly  so  called,  is  most 
commonly  confined  to  the  larynx  and  upper  part  of  the  trachea, 
degenerating  as  above  stated,  both  upwards  and  downwards,  into 
a  substance  of  a  softer  texture,  which  is  the  chief  cause  of  the 
imminent  suffocation   which  sometimes  occurs  even  during  the 

*  Hufeland's  Journal,  vi.  B.  p.  bo'J. 


CROUP.  131 

first  hours  of  the  attack.     In  other  cases,  the  false  membrane 
extends  over  a  great  portion  or  even  the  whole  of  the  bronchial 
ramifications,  from  which  it  may  occasionally  be  separated,  after 
death,  by  a  very  slight  degree  of  force.     Sometimes  the  disease 
is  confined  to  the  bronchi  and  their  branches,   there  being  no 
trace    of   it    in    the    larynx    and    trachea.*     More    commonly, 
as   has  been  shown   by  Bretonneau,  the  inflammation  commences 
on   the   tonsils    of  the  pharynx,    and   from  thence   spreads,    at 
the   same  time,   downwards  to  the  larynx  and  upwards    to  the 
cavity  of  the   nostrils,  which  latter  it  sometimes  entirely  covers. 
The  affection  usually  stops  at  the  oesophagus,  but  occasionally  the 
false  membrane  extends  to  the  stomach.     In  one  instance,  M.  Bre- 
tonneau saw  a  false  membrane  formed  behind  the  ear  of  a  child ; 
and  Dr.  Bourgeoise,  of  Paris,  has  published  his  own  case,  in  which 
a  similar  formation  took  place  round  the  anus.     In  children,  the 
disease,   almost  always    begins   in    the  bronchi  or  larynx,  and 
very  rarely  extends  beyond  the  glottis  ;  while  in  adults  it  more 
frequently  originates,  as  has  been  above  stated,  on  the  tonsils  or 
pharynx.f     M.  Bretonneau  has  successfully  shown  that  such  cases 
of  what  may  be  called  plastic  angina,  have  been  frequently  mista- 
ken for  the  gangrenous  affections  of  the  same  parts  (cyanche  ma- 
ligna.)    Perhaps  this  author  may  have  gone  somewhat  too  far  in 
limiting  the  existence  of  the  last  disease.f     Certain  it  is  that  exam- 
ples of  it  occur  as  wellwith  as  without  false  membranes.  In  a  case  of 
scarlatina  in  a  man  of  middle  age,  which  was  under  my  care  in  the 
Necker  Hospital,  it  was  quite  clear  to  me  that  the  gangrenous  es- 
chars of  the  tonsillary  membrane  preceded  the   appearance  of  the 
false  membrane,  which,  in  the  end,  extended  into  the  larynx  ;  and 
it  is  quite  easy  to  conceive  that  the  inflammation  by  which  nature 
circumscribes  the  progress  of  the  gangrene,  or,  as  some  may  think, 
which  is  excited  by  the  irritation  of  the  eschar, — may  be  itself  of 
a  plastic  kind  and  give  rise  to  a  false  membrane,  just  as  it  is  pos- 
sible that  the  intensity  of  the  inflammation  may  occasion  the  gan- 
grene.    In  the  former  case  we  have  an  instance  of  idiopathic  gan- 
grene ;  in  the  latter  a  case  of  crusty  or  pellicular  pharyngitis  ac- 
companied by  gangrene.^     I  am  not  acquainted  with  any  instance 
of  croup  which  originated  in  the  larynx  or  bronchi,  being  accom- 

*  In  this  case  the  disease  is  not  in  reality  croup,  but  that  variety  of  bronchitis 
accompanied  by  false  membranes,  described  by  Horstius,  Raickem  and,  Guersent 
(Diet,  de  Med.  t.  vi.)  and  we  must  no  more  confound  them  under  one  head  than 
we  confound  laryngitis  with  the  acute  mucous  catarrh. — (M.  L.) 

t  In  Mr.  Ramsey's  cases,  which  will  be  noticed  in#a  subsequent  note,  all  the 
subjects  were  children. —  Transl. 

X  See  the  article  Augine  Couenneuse  in  the  Diet,  de  Medicine,  by  Guersent. 

§  Bretonneau  does  not  deny  that  gangrene  may  be  the  consequence  of  the  crus- 
ty or  pellicular  inflammation  ;  but  merely  asserts  its  extreme  rarity  ;  he  himself 
not  having  met  with  a  single  example  of  it  in  more  than  fifty  cases  examined  af- 
ter death.— (M.  L.) 


132  croup. 

panied  by  gangrene ;  but  in  cases  where  it  has  sprung  from  the 
extension  of  a  gangrenous  and  plastic  cynanche.  I  have  myself 
seen  gangrenous  eschars  on  the  mucous  membrane  both  of  the  la- 
rynx and  pharynx.  In  these  cases,  the  false  membrane  was  of  a 
dirty  greyish  or  green  hue,  and  exhaled  the  horrible  fetor  peculiar 
to  gangrene.* 

*  No  reasonable  doubt,  I  think,  can  be  entertained  by  the  readers  of  M.  Bre- 
tonneau's  work,  that  the  croup  and  cynanche  maligna  are   often   identical,  or 
rather,  that  what  has   often   been  considered   as  a  gangrenous   atfection   of  the 
throat,  is  merely  an  inflammation  of  the  same  kind   as  that  of  croup,  and  char- 
acterized by  the  formation  of  a  membranous  exudation  of  a  peculiar  kind.     But 
however  we  may  concede  the  identity  of  the  nature  of  the  inflammation  in  the 
two  diseases,  we  cannot  admit  the  proposition  that  simple  croup,  that  is,  croup 
unaccompanied  by  any  pharyngeal  affection,  does  not  exist  as  a  separate  disease. 
Neither,  I  think,  can  we  agree  with  this  writer  in  considering  the  inflammation 
of  the  mucous  membrane  in   the  scarlatina  anginosa,  as  specially  different  from 
that  which  occurs  unaccompanied  by  cutaneous  eruption,  and  which  he  describes 
under  the  name  of  Diphtherile.     The  frequently  fatal  termination  of  the  angina 
maligna,  whether  accompanied  by  a  cutaneous  eruption  or  not,  by  extending  to 
the  windpipe,  is   noticed  in  all  our  best  English  writers  on  this  disease.     The 
account  given  by  Dr.  Starr  of  an   epidemic  of  this   kind,  which  raged  in  Corn- 
wall in  the  year  1748,  and  which  is  described   by  him  in  No.  4!)5  of  the  Philo- 
sophical Transactions  under  the  name  of  Morbus  Strangulatorius ,  is  noticed  by 
M.  Bretonneau.     Dr.  Fothergill,  whose  treatise   on    the  malignant  sore  throat 
appeared  in  1748,  does  not  notice  this  termination  in  his  general  history  of  the 
disease;  yet  we  find,  on  referring  to  the  fatal  cases  recorded  by  him,  that  "  great 
difficulty  of  breathing"  took  place  in  all,  previously  to  the  fatal  termination. 
See  his  works  by  Lettsom,  vol.  i.  p.  379,  382,  388.     In  Huxam's  account  of  the 
epidemic  of  1752-3  the  same  termination  is  distinctly  noticed.     In  speaking  of 
the  expectoration   of  what  he   terms  the  sloughs,  he   says  that  a  piece  of  the 
internal  membrane  of  the  icindpipe  was  discharged,  meaning,  of  course,  the  false 
membrane   of  croup.     He  also  notices   the   disease  as  "  killing  suddenly  in  a 
peripneumonic  manner." — Dissert,   on  the  Malig.  Ulcerous,  Sore   Throat.     Dr. 
James  Johnstone,  the  elder,  in  his  u  Dissertation  concerning  the  malignant  epi- 
demical  fever  of  1756,"  speaking  of  the  malignant  angina,   says,    "At  last, 
when  death   is   at  hand,  respiration  becomes   unexpectedly  difficult,  quick,  and 
peripneumonic."  p.  10.     But  it  is  in   the  treatise  by  Dr.  James  Johnstone,  son 
of  the  preceding  writer,  that  we  find  the  connexion  of  the  angina  maligna  and 
croup, — and  indeed   the  very  identity  of  these  contended  for  by  Bretonneau, — 
fully  and  distinctly  stated.     See   his  Treatise  on   the  Malignant  Angina,  Wor- 
cester, 1779.     "  There  is  but  one  other  species  of  angina  (he  says)  from  which 
this  disease  [A.  miligna]   requires  any  distinction,  and   that  is   the  croup.     A 
small  degree  of  attention  to  the  several  divisions  of  that  distemper,  which  have 
been  made  by  the  best  writers,  will   show  that  in  respect  to  many  of  the  cases 
there  can  be  no  distinction,  because  in  reality  there  is  no  difference,"  p.  54.     He 
accordingly  divides  the  disease  into  two  species — 1.  malig.  tonsillaris,  and  A. 
malig.  trachcalis.     In  Dr.  Withering's  "  Account  of  the  Scarlet  Fever  and  Sore 
Throat,"  published  in  the  same  year  as  Dr.  Johnstone's  treatise,  the  same  exten- 
sion of  the  disease  to  the  passages  opening  into  the  pharynx,  is  noticed.     "  This 
affection  of  the  fauces  (he  says)  in  some  patients  seemed  to  extend  down  the  gullet 
to  the  stomach  .  . ..  .  . :  in  others  it  spread  itself  down  the  windpipe  to  the  lungs, 

as  was  evident  from  the  cough,  the  strait  breathing,  and  other  peripneumonic 
symptoms.  And  in  others  again,  its  progress  along  the  Eustachian  tube  was  in- 
dicated by  sharp  pains  in  \he  ear,"  p.  13.  In  Dr.  Cullen's  account  of  the  cynan- 
che maligna  it  is  stated,  that  "  from  dissections  it  appears  that  in  the  C.  Malig. 
the  larynx  and  trachea  are  often  affected  in  the  same  manner  as  in  the  C.  tra- 
chealis  ;  and  it  is  probable  that,  in  consequence  of  that  affection,  the  C.  maligna 
often  proves  fatal  by  such  a  sudden  suffocation  as  happens  in  the  proper  cynanche 
tracheahs."     Thomson's  ed.  vol.  ii.  39 ;  and  in  his  chapter  on  C.  Trachealis  he 


croup.  133 

Symptoms. — When  the  disease  begins  in  the  larynx,  in  its 
onset  it  is  frequently  altogether  like  that  of  a  common  cold  ;  but 
after  the  lapse  of  some  hours,  sometimes  only  after  one  or  two 
days,  the  cough  becomes  more  violent,  resounding  in  the  larynx 
and  trachea  as  in  a  metallic  tube,  and  with  a  peculiarity  of  cha- 
racter which  has  been  compared  to  the  crowing  of  a  cock.  Even 
the  voice,  and  yet  more  the  inspirations  which  occur  in  the  fits  of 
coughing,  have  something  of  the  same  sound.  This  is  denomi- 
nated the  croupy  voice  or  cough.  With  this  there  is  very  great 
oppression,  which  is  changed  into  imminent  suffocation,  particu- 
larly when  the  false  membrane  begins  to  separate.  This  threat- 
ening suffocation  is  equally  excited  by  inspiration,  expiration,  or 
cough,  and  soon  becomes  real  if  the  loosened  fragments  of  false 
membrane  are  not  expectorated.  If  the  disease  is  confined  to 
the  bronchi,  the  same  symptoms  exist,  with  the  exception  of  the 
croupy  sound.  If  it  commences  in  the  fauces,  spots  of  a  yel- 
lowish or  greenish  color,  surrounded  by  a  deep  red,  are  at  first 
perceived  on  the  tonsils,  the  pillars  of  the  veil  of  the  palate  or 
the  back  part  of  the  pharynx.  These  specks  gradually  extend, 
unite,  and  increase  in  thickness,  so  as  at  last  to  form  a  complete 
crust,  like  that  of  inflamed  blood,  lining  the  whole  entrance  of 

asserts  the  fact  still  more  explicitly.  "  It  frequently  happens  that  the  C.  Malig- 
na, which  has  its  first  and  principal  seat  in  the  mucous  membrane  of  the  tonsils 
and  uvula,  communicates  and  spreads  down  to  the  glottis  and  trachea,  and  to  a 
considerable  length  in  the  bronchia:,  and  is  there  attended  with  the  same  sloughs 
that  happen  in  the  fauces,  and  then  it  will  produce  all  the  symptoms  of  the  C. 
stridula,  or  trachealis. — Ibid.  p.  43.  In  a  paper  published  by  Mr.  Rumsey,  in 
the  Transac.  of  a  Soc.  for  the  improvement  of  Med.  and  Chirur.  Knowledge,  con- 
taining  an  account  of  an  epidemic  croup  observed  by  him  in  the  year  17i)0,  the 
diphtheritic  affection  of  the  tonsils  is  noticed.  "  Most  of  the  cases  (he  says) 
which  occurred  in  November  and  afterwards,  were  attended  with  inflammation 
and  swelling  of  the  tonsils,  uvula  and  velum  pendulum  palati,  and  frequently 
large  films  of  a  white  substance  were  formed  on  the  tonsils."  vol.  ii.  p.  20.  The 
same  appearances  have  been  more  recently  recorded  by  Mr.  Mackenzie  in  the 
Edin.  Med.  and  Surg.  Journ.  for  April  1825,  by  Mr.  Pretty  in  the  Lond.  Med* 
and  Phys.  Journ.  for  January,  1826,  and  by  Dr.  Hamilton  in  the  Ed.  Journ.  of 
Med.  Science  lor  October  1826.  The  first  writer  recommends  the  topical  use  of 
a  strong  solution  of  lunar  caustic,  in  the  same  manner  as  the  muriatic  acid  is 
applied  by  Bretonneau. 

For  the  best  English  account  of  simple  croup,  the  reader  is  referred  to  Dr. 
Chcyne's  work  on  the  pathology  of  the  Larynx  and  Bronchi ;  and  to  Mr.  Porter's 
Surgical  Pathology  of  the  Larynx  and  Trachea.  On  the  subject  of  croup,  as  on 
must  other  contested  points  in  medical  history,  much  confusion  has  been  occa- 
sioned by  the  circumstance  of  different  names  being  given  to  the  same  disease, 
on  the  one  hand,  and  of  different  diseases  being  described  under  the  same  name, 
on  the  other  hand.  See  the  various  writers  on  Laryngitis,  Tracheitis,  Bronchi- 
tis, Acute  Asthma,  Bronchial  Polypus,  Suffocative  Catarrh,  <^c.  fyc.  See  also  the 
articles  Croup  and  Throat,  diseases  of,  in  the  Cyclopaedia  of  Pract.  Med.  the 
former  by  Dr.  Cheyne,  the  latter  by  Dr.  Tweedie  :  and  tfce  elaborate  article  by 
Dr.  Copland,  in  the  Diet,  of  Pract.  Med.  In  these  articles  much  of  the  practical 
difficulties  thrown  round  the  affections  of  the  pharynx,  larynx,  and  trachea,  by 
I  he  French  authors,  will  be  found  removed  by  a  more  discriminative  classifica- 
tion of  the  diseases. —  Transl. 


134  croup. 

the  fauces,  and  extending  in  a  greater  or  less  degree  into  the 
larynx,  trachea,  and  bronchi.* 

If  the  croupy  affection  results  from  a  gangrenous  angina,  we 
can  sometimes  distinguish  the  eschars  before  the  formation  of  the 
false  membrane.f  In  all  cases  the  gangrene  is  indicated  by  its 
peculiar  odor,  sooner  than  by  any  other  symptom.  If  the  dis- 
ease terminates  favorably,  we  can,  day  by  day,  observe  the 
progress  of  the  cure  in  examining  the  interior  of  the  throat :  the 
false  membrane  falls  off  and  is  replaced  by  an  exudation  of  a 
thinner  and  less  plastic  character,  or  one  not  at  all  differing  from 
the  mucous  discharge  of  catarrh.  At  other  times,  the  membrane, 
in  place  of  being  detached,  is  gradually  absorbed, — becoming  at 
first  thinner  and  less  opaque,  then  sufficiently  transparent  to 
show  the  redness  of  the  membrane  beneath  it,  and  finally  disap- 
pearing altogether. 

Croup,  even  when  most  partial,  is  almost  always  accompanied 
by  great  constitutional  disturbance.  In  the  majority  of  cases 
the  symptomatic  fever  is  acute  and  very  severe  ;  the  action  of 
the  heart  being,  at  the  same  time,  frequently  irregular.  In  some 
cases,  particularly  such  as  occur  in  hospitals,  the  state  of  the 
system  is  very  different,  there  being  evident  marks  of  a  septic 
change  in  the  fluids  of  the  body :  the  pulse  is  but  little  accele- 
rated, the  skin  harsh  and  dry,  the  debility  extreme,  and  the 
breath  fetid  even  where  no  gangrenous  specks  exist.  This  va- 
riety is  denominated  asthenic  by  Guersent  and  Bretonneau.  In 
it  the  falss  membrane,  especially  that  lining  the  throat,  is  fre- 
quently soft  and  friable,  like  soft  cheese. 

The  symptoms  above  enumerated  are  sufficient  to  indicate  the 
disease  when  they  occur  in  a  certain  number  together ;  but  it 
must  be  allowed  that,  if  we  except  the  expectoration  of  mem- 

.  *  While  acknowledging  the  existence  of  true  gangrene  in  certain  cases  of  the 
cynanche  maligna,  it  is  evident  that  Laennec  does  not  recognise  any  essential  dif- 
ference between  this  affection  and  true  croup,  except  that  of  site.  Accordingly, 
we  find  him  coinciding  with  Bretonneau  and  Guersent,  in  regarding  Croup  sim- 
ply as  a  plastic  or  pseudo-membranous  inflammation, either  confinedjto  the  larynx, 
or  extending  at  the  same  time  to  the  trachea  and  bronchi,  but  not  rising  above 
the  glottis  ;  while  the  cynanche  maligna  is  regarded  as  an  inflammation  of  precise- 
ly a  similar  kind,  but  commencing  in  the  throat,  and,  after  occupying  the  tonsils 
and  pharynx,  spreading  more  or  less  rapidly,  over  the  veil  of  the"  palate  and  na- 
sal fossa;,  on  the  one  hand,  and,  on  the  other,  creeping  into  the  larvnx.  trachea, 
and  bronchi.  Hence,  it  will  be  observed,  that  in  the  remaining  portion  of  the 
present  chapter,  he  does  not  separate  the  consideration  of  the  two  affections  — 
(M.  L.) 

t  Bretonneau  has  shown  that  these  pretended  eschars,  which  "  we  can  dis- 
tinguish before  the  formation  of  the  false  membrane,"  are  nothing  else  but  the 
false  membrane  itself  changed  by  the  contact  of  the  air,  and  rendered  foetid  by 
decomposition.  (Op.  Cit.  p.  44,  et  teg.)—(M.  L.)— But  it  does  not  follow  that 
this  is  invariably  the  case ;  and  there  seems  no  good  reason  why  the  inflamma- 
tion surrounding  a  gangrenous  speck  may  not  (as  is  above  observed  by  Laennec) 
be  of  a  plastic  kind  and  give  rise  to  the  "diphtheritic  membrane.—  Transl 


croup.  135 

branaceous  fragments,  or  the  appearance  of  false  membrane  in 
the  fauces,  there  is  not  one  of  them  which  is  pathognomonic* 
The  croupy  voice  or  sound,  independently  of  its  not  being  always 
well-marked,  does  not  occur  until  after  the  disease  has  made 
great  progress.  The  cough  is  similar,  or  nearly  so,  in  other  dis- 
eases, particularly  in  certain  cases  of  hooping  cough,  in  which 
the  sonorous  inspirations  sometimes  perfectly  resemble  the  crow- 
ing of  a  cock. 

I  have  only  met  with  one  case  of  bronchial  croup,  within  these 
few  years,  of  sufficient  severity  to  be  recognized  from  the  begin- 
ning, and  which  was  soon  more  fully  characterized  by  the  expec- 
toration of  fragments  of  false  membrane  moulded  on  bronchi  of 
different  diameters.  In  this  case,  which  occurred  in  a  child  six 
years  old,  the  stethoscope  detected,  during  the  whole  course  of 
the  disease,  no  other   respiratory  sound,  but  that  of  a  dry  respi- 

*  This  is  so  much  the  case  that  it  has  been  found  necessary  to  admit  the  ex- 
istence of  a  false  croup,  in  which  there  is  no  formation  of  false  membrane,  and 
which  yet,  at  its  very  commencement,  exhibits  all  the  symptoms  of  the  full- 
formed  disease,  insomuch  that  the  two  affections  are  scarcely  ever  sufficiently 
discriminated  to  prevent  the  administration  of  improper  or  useless  remedies. 
In  our  difficulties,  indeed,  we  have  merely  negative  and  insufficient  signs  to 
direct  us — such  as  a  little  less  fever,  a  less  hissing  respiration  between  the  fits 
of  coughing,  less  complete  loss  of  voice,  and  a  more  rapid  diminution  of  the 
symptoms.  I  say  nothing  of  the  negative  signs  adduced  by  Bretonneau,  viz. 
the  want  of  the  redness  of  the  tonsils,  and  of  the  swelling  of  the  lymphatic 
glands  of  the  neck,  because  they  would  only  be  then  valuable  if  the  inflamma- 
tion of  croup  always  commenced  in  the  pharynx,  which  remains  to  be  proved. 
(M.L.) 

After  this  disheartening  statement,  I  cannot  resist  the  opportunity  of  laying  be- 
fore the  student  the  following  graphic  delineation  of  an  attack  of  the  true  croup, 
by  a  most  experienced  observer,  and  not  without  hopes  that  it  may  so  fix  itself 
on  the  mind  as  to  prove  an  ever-present  touchstone  or  pathognomonic  standard, 
in  actual  practice. — "  More  generally  the  patient  has  been  for  some  time  in  bed 
and  asleep  before  the  nature  of  the  disease  with  which  he  is  threatened,  'is 
apparent;  then,  perhaps  without  waking,  he  gives  a  very  unusual  cough,  well 
known  to  any  one  who  has  witnessed  an  attack  of  the  croup ;  it  rings  as  if  the 
child  had  coughed  through  a  brazen  trumpet, — it  is  truly  a  tussis  clangosa ;  it 
penetrates  the  walls  and  floor  of  the  apartment,  and  startles  the  experienced 
mother — '  Oh  I  am  afraid  our  child  is  taking  the  croup  :'  she  runs  to  the  nursery, 
finds  her  child  sleeping  softly,  and  hopes  she  may  be  mistaken.  But  remaining 
to  tend  him,  before  long  the  ringing  cough,  a  single  cough,  is  repeated  again  and 
again  ;  the  patient  is  roused  and  then  a  new  symptom  is  remarked, — the  sound 
of  his  voice  is  changed;  puling  and  as  if  the  throat  were  swelled,  it  corresponds 
with  the  cough  :  the  cough  is  succeeded  by  a  sonorous  inspiration,  not  unlike 
the  kink  of  pertussis  ;  the  breathing  hitherto  inaudible  and  natural,  now  be- 
comes audible,  and  a  little  slower  than  common,  as  if  the  breath  were  forced 
through  a  narrow  tube  ;  and  this  is  the  more  remarkable  as  the  disease  advan- 
ces. A  blush  of  inflammation  may  sometimes  be  detected  on  the  fauces,  and,  in 
some  rare  instances,  a  slight  degree  of  swelling  round  the  larynx,  and  the  child 
complains  of  uneasiness  in  his  throat,  and  says  he  is  chocking.  The  ringing 
cough  followed  by  crowing  inflammation  ;  the  breathing,  as  if  air  were  drawn 
into  the  lungs  by  a  piston ;  the  flushed  face;  the  tearful  and  bloodshot  eye; 
quick,  hard,  and  incompressible  pulse  ;  hot,  dry  skin;  thirst,  and  high-colored 
urine — form  a  combination  of  symptoms  which  indicate  the  complete  establish- 
ment of  the  disease. *' — Cyclopaedia  of  Pract.  Med.  Art.  Croup,  (vol.  i.  p.  493,) 
by  John  Cheyne,  M.  D. —  Transl. 


136  croup. 

ration,  evidently  tubular  or  bronchial,  unmixed  with  any  of  that 
crepitous  dilatation  of  the  pulmonary  cells  so  strongly  marked  in 
infancy.  This  sign  coinciding  with  a  natural  resonance  of  the 
chest,  will  suffice  (if  it  is  constant,  as  I  presume  it  will  be  found 
to  be)  to  indicate  the  bronchial  croup ;  since  it  exists  in  no  other 
case,  except  sometimes  and  in  a  much  less  degree,  in  dilatation 
of  the  bronchi ;  a  chronic  affection,  generally  of  very  partial  ex- 
tent, and  which  can  hardly  be  confounded  with  croup  by  the 
most  inattentive  observer.* 

Occasional  causes. — Croup  is  unquestionably  much  more  fre- 
quent in  infancy  than  adult  age.  It  is  often  epidemic,  particu- 
larly in  places  exposed  to  the  north  and  north-west  winds,  and 
when  these  winds  are  more  than  usually  prevalent.  Eruptive 
fevers,  particularly  scarlatina,  are  sufficiently  often  complicated 
with  this  disease,  to  justify  our  considering  them,  or  the  causes 
of  them,  as  among  the  causes  of  croup.  The  wide  extension  of 
this  plastic  inflammation  of  the  mucous  membranes,  and  its 
affecting  parts  very  distant  and  even  unconnected  with  each  other, 
might  lead  us  to  suspect,  at  least,  that  its  cause  is  rather  some 
special  alteration  of  the  fluids  than  a  primary  irritation  of  the 
membrane  on  which  it  is  developed.  The  asthenic  croup  pre- 
vails particularly  in  hospitals,  and  would  seem  occasionally  to  be 
propagated  by  infection.  Indeed,  many  practitioners  have  looked 
upon  croup  in  general,  as  well  as  the  malignant  angina,  as  con- 
tagious. This  question  may  still  be  considered  as  undetermined  ; 
however,  the  case  of  M.  Bourgeoise,  already  alluded  to,  would 
seem  to  show  that  it  is  not  safe  to  respire  too  closely  the  breath 
of  patients  laboring  under  this  disease.f 

Treatment. — If  croup  is  not  accompanied  by  a  strongly  marked 

*  It  must  be  admitted  that  the  brief  exposition  given  by  Laennec  of  the  symp- 
toms and  progress  of  the  plastic  inflammation  of  the  air  passages  is  insufficient : 
it  is  manifest  that  the  whole  chapter  was  written  in  great  haste.  For  more  com- 
plete details  I  refer  the  reader  to  the  writers  quoted  by  Laennec,  viz.  the  Trea- 
tise on  Diphtherite,  by  JVI.  Bretonneau,  and  the  two  articles  of  M.  Guersent  in 
the  Diet,  de  Med. 

The  stethoscopic  phenomena  are  of  no  value  in  the  true  croup.  Auscultation 
practised  on  the  larynx  or  between  the  scapulae,  enables  us  merely  to  hear  more 
distinctly  the  hissing  sound  so  perceptible  by  the  ear. — (M.  L.) 

To  the  works  named  by  Dr.  Mer.  Laennec  in  the  above  note,  I  would  add 
several  of  those  referred  to  at  the  end  of  this  chapter,  particularly  those  of 
Cheyne,  J  urine,  Rubini,  and  Copland.—  Transl. 

t  The  disease  of  M.  Bourgeoise  was  a  case  of  the  pellicular  or  pseudo-gan- 
grenous angina,  the  contagious  nature  of  which  has  been  rendered  extremely 
probable  by  the  observation  of  Bretonneau,  Guersent,  and  others  ;  but  the  true 
croup  appears  insusceptible  of  transmission  by  contagion.  These  two  forms  of 
plastic  inflammation  differ  in  some  other  points  of  view,  which  may  be  here  no- 
ticed :  for  instance,  we  have  no  account  of  an  epidemic  of  the  true  or  simple 
croup,  while  the  pseudo-gangrenous  or  pellicular  aijgina,  is  rarely  sporadic; 
again,  the  true  croup  is  rare  among  adults,  but  the  pellicular  angina  affects  indif- 
ferently adults  and  children,  although  it  in  general  rages  more  severely  amonjr 
the  latter.— (M.  L.)  J  t 


croup.  137 

asthenic  diathesis,  or  does  not  occur  in  very  young  infants,  the 
treatment  ought  to  commence  with  one  or  two  bleedings  from  the 
arm  or  foot.  In  doubtful  cases,  it  would  seem  preferable  rather 
to  omit  bleeding,  than  to  destroy,  by  injudicious  depletion,  the 
powers  requisite  for  the  separation  and  excretion  of  the  false 
membrane.*  Blood-letting,  indeed,  in  this,  as  in  other  diseases 
which  have  reached  the  period  of  suppuration,  is  rather  a  pre- 
ventive of  future  mischief  than  a  measure  likely  to  lessen  that 
which  already  exists.  And,  in  fact,  in  the  case  in  question,  the 
danger  arises  much  less  from  the  inflammation  than  from  the  me- 
chanical obstacle  to  the  respiration  occasioned  by  the  false  mem- 
brane. In  children,  leeches  to  the  throat,  repeated  more  or  less 
frequently  according  to  the  strength  of  the  patient  and  the  seve- 
rity of  the  disease,  may  advantageously  take  the  place  of  vene- 
section ;  and  in  adults  their  repeated  application  may  be  useful 
after  general  bleeding  has  been  had  recourse  to.  Leeches  have 
the  advantage  of  producing,  in  addition  to  the  unloading  of  the 
capillaries  in  the  vicinity  of  the  affected  part,  a  sort  of  local 
eruption,  which  unquestionably  is  sometimes  beneficial  as  a  deri- 
vative. Other  derivatives,  however,  and  of  the  most  energetic 
kind,  must  be  put  in  requisition,  particularly  blisters  and  sinap- 
isms. These  are,  in  general,  more  advantageously  applied  to  the 
lower  extremities,  than  in  the  vicinity  of  the  disease.  Good 
effects  have,  nevertheless,  been  obtained  from  the  application  of 
a  cataplasm,  wetted  with  muriatic  acid  to  the  anterior  part  of  the 
larynx.  Perhaps  this  may  act  otherwise  than  as  a  rubefacient. 
It  is  at  least  certain,  that  experience  has  proved  that  no  other 
application  is  so  effectual  in  removing  the  false  membrane  from 
the  fauces,  as  that  recommended  by  Van  Swieten,  viz.  one  part 
of  muriatic  acid  and  three  of  honey,  with  which  the  specks  are 
annointed  by  means  of  a  pencil.f     All  practitioners  who  have  had 

*  On  this  passage  Dr.  Cheyne  makes  the  following  judicious  remarks,  in  the 
article  quoted  above.  "  As  to  the  question  of  bleeding  in  croup  when  the  dis- 
ease is  once  established,  no  doubt  ought  to  exist,  unless  perhaps  we  may  hesi- 
tate with  respect  to  its  stage.  If  the  patient  is  in  the  first  or  inflammatory  stage, 
no  experienced  physician  will  omit  bleeding;  if  in  the  second,  or  that  of  sup- 
puration, no  physician  will  propose  it.  If  it  were  doubtful  to  which  stage  the 
symptoms  belonged,  it  would  be  preferable  to  bleed;  the  anceps remedium ought 
to  be  preferred.  Nothing  but  the  mingling  together  of  incongruities  and  con- 
sequent misapprehensions  of  croup,  could  have  induced  an  eminent  physician 
like  Bretonneau  to  make  so  dangerous  an  observation  as  the»  following :  'I  am 
forced  to  declare,  contrary  to  the  received  opinion,  that  bleeding  in  croup  has 
done  harm,  and  accelerated  rather  than  retarded  the  spread  of  the  coriaceous 
inflammation.  I  did  not  abandon  this  measure  till  after  the  reiterated  proofs  of 
its  injurious  effects.'  Physicians  need  not  be  told  not  to  bleed  in  cynanche 
maligna,  it  never  was  their  practice  to  do  so,  nor  would  they  willingly  bleed  in 
any  form  of  membranous  angina  ;  but  if  they  renounce  blood-letting  in  the  first 
stage  of  croup,  which  they  are  taught  to  do  by  this  sweeping  dogma  of  alleged 
experience,  they  will  part  with  the  best  shaft  in  their  quiver."  Cyc.  of  Pract. 
Med.  vol.  i.  p.  500—  Transl. 

f  The  ri'searrhes  of  Bretonneau  have    afresh  demonstrated  the  importance  of 

18 


138  croup. 

occasion  to  see  a  good  deal  of  this  disease,  will  readily  admit, 
that  these  measures,  although  very  rational  and  conformable  to 
the  results  of  experience  in  the  treatment  of  inflammatory,  dis- 
eases in  oreneral,  are  nevertheless  rarely  sufficient,  and  that  very 
few  well  characterized  classes  have  yielded  to  their  influence. 
Others  have  consequently  been  had  recourse  to.  I  shall  here 
notice  those  only  which  have  been  found  decidedly  beneficial. 
Of  this  kind  are  emetics  repeated  daily  or  even  twice  a  day.* 
They  evidently  accelerate  the  separation  of  the  adventitious 
membrane,  and  favor  its  expulsion.  However  valuable  this 
treatment  may  be,  and  I  have  myself  obtained  cures  which  I 
could  attribute  to  it  alone,  it  is  no  doubt  too  true  that  the  greater 
number  of  cases  still  prove  fatal,  even  when  it  is  called  in  to  aid 
the  means  already  detailed.  The  internal  use  of  hydrosulphuret 
of  potass  was,  some  years  since,  cried  up  as  a  sort  of  specific  in 
croup.  It  is  one  of  the  ancient  family  of  the  alkaline  resolvents, 
by  which  the  chemical  physicians,  followers  of  Sylvius  of  Ley- 
den,  proposed  to  correct  the  too  great  plasticity  or  viscidity  of 
the  fluids,  and  even  to  dissolve  concretions  already  formed.  I 
have  before  spoken  of  this  alkaline  treatment.  In  the  present 
case  it  is  sufficient  to  remark,  that  its  effects  are  too  slow  to  be 
of  any  use  in  a  disease  of  such  rapid  progress  as  croup.  In  small 
quantity  its  effects  are  insignificant ;  and  in  larger  and  more  re- 
peated doses,  it  must  be  more  injurious  as  an  irritating,  acrid, 
and  almost  caustic  substance,  than  it  can  be  beneficial  as  an  al- 
kaline remedy.  Pretty  numerous  successful  results  have  been 
obtained  from  mercurial   frictions    exhibited  in    such    doses   as 

topical  applications  in  the  plastic  inflammations  of  the  air  passages.  The  mix- 
ture of  Van  Swieten,  and,  still  better,  the  pure  muriatic  acid  applied  by  means 
of  a  sponge  to  the  affected  part,  were  unquestionably  beneficial  in  the  epidemic 
of  Tours  ;  and  however  painful  the  practice  may  be,  it  can  never  henceforth  be 
omitted  with  propriety,  in  the  cases  where  the  disease  commences  in  the  pha- 
rynx. When  it  originates  below  the  glottis,  that  is,  in  the  true  croup,  Breton- 
neau  has  proposed  (and  daily  experience  of  its  happy  effects  justifies  the  propo- 
sal) to  introduce  pulverised  alum  into  the  air  passages.  This  is  affected  by 
means  of  a  small  hollow  cylinder  of  wood  containing  the  alum,  to  which  two 
tubes  are  attached  ;  through  one  of  these  the  operator  blows  forcibly,  so  as  to 
convey  the  powder  to  its  destination.  The  operation  is  repeated  two  or  three 
times  daily.  It  immediately  occasions  a  great  heat  in  the  throat  and  an  intense 
thirst,  which  are  allayed  by  allowing  the  patient  to  drink  cold  water  at  discre- 
tion. Insufflations  of  this  kind  may  be  beneficially  applied  in  other  diseases. 
M.  Ambroise  Laennec  of  Nantes  has  used  them  with  the  greatest  success  in  se- 
vere tonsillitis,  in  the  variolous  cynanche,  and  in  oedema  of  the  glottis  ;  (Revue 
Med.  Oct.  1828  ;)  and  we  might  anticipate  happy  results  from  the  practice  in 
laryngaeal  phthisis,  if  it  did  not  unfortunately  happen  that  this  affection  is  al- 
most always  complicated  with  tuberculous  disease  of  the  lungs— (M.  L.) 

*."  In  very  few  cases  have  I  known  the  child  survive  the  second  stage  of 
croup  ;  and  in  all  of  these  the  children  recovered  while  using  a  solution  of  tar- 
tarised  antimony.  Emetics  I  had  repeatedly  given  in  the  second  stage  of  croup  - 
but  in  these  casts  the  patients  were  kept  sick  for  two  or  three  days,  with  scarce 
any  interval.  —  Cheyne's  Pathology  of  the  Bronchi,  &c.  p.  52.—  transl 


croup.  139 

speedily  to  produce  salivation ;  and  in  the  actual  state  of  the 
science  I  think  no  prudent  practitioner  ought  to  neglect  this  me- 
thod  conjointly   with  blood-letting  and  emetics.*     The  efficacy 

*  It  is  hardly  necessary  to  inform  the  English  reader  that  the  use  of  mercury, 
in  the  form  of  calomel,  given  internally  in  large  and  frequently  repeated  doses, 
has  heen  carried  to  a  great  extent  in  this  country.  This  practice  was  introduced 
by  Dr.  Rush,  and  was  extensively  used,  and  at  one  time  cried  up  as  almost  a 
specific,  by  Dr.  Hamilton  of  Edinburgh.  He  administered  the  medicine  in  dos- 
es of  from  one  to  five  grains  every  hour.  In  the  later  editions  of  his  treatise, 
tins  author  admits  that  he  had  exaggerated  the  efficacy  of  calomel  in  this  dis- 
ease ;  an  opinion  in  which  I  believe  he  will  be  joined  by  every  experienced 
practitioner.  It  would  appear  from  Dr.  Bretonneau's  treatise,  that  this  practice, 
although  fallen  into  comparative  disuse  in  this  country,  is  likely  to  be  revived 
in  France. —  Transl. 

LITERATURE  OF  CROUP. 

1718.  Blair  (Pat.  M.  D.)  Miscell.  obs.  on  the  practice  of  Physic.     2  vol.  Lond. 

8vo. 
1749.  Ghisi  (Mart.)  Lettere  mediche.      Cremona,  1749.     4to. 

1764.  Wilcke  (II.  C.  et  auriyillius  (S.)     De  Angina  Infantum.     Upsal.  4to. 

1765.  Home  (F.,  M.  D.)  an  enquiry  into  the  nature,  &c.  of  Croup.  Edin.  8vo. 
1769.  Murray  (J.  A.)  Abhandl.  von  einer  bosartigen  Braune,  &c.      Goett.  8vo. 

1778.  Michaelis  (C.  F.)  De  angina  polyposa.      Goett.  1778.  8vo. 

1779.  Johnstone  (J.,  M.  D.)  Treatise  on  malignant  angina.  IVorcest. 1779.  8vo. 
1794.  Rush  (B.,  M.  D.)  Obs.   on  the   cynanche    trach.   (Med.  Obs.   &   Inq.)— 

Phil.  8vo. 

1794.  Alexander  (Disney,  M.  D.)  Treat,  on  the  nature  of  cynanche  trach.  or 
croup.     Huddcrsf.  8vo. 

1798.  Archer  (J.)  Dissertation  on  cyn.  trach.  commonly  called  croup. — Phil- 
ad.  8vo. 

1801.  Cheyne  (J.,   M.D.)  Essays   on   the  dis.   of  children.      I.  On   croup.— Ed- 

in. 8vo. 

1802.  Schwilgue  (C.  J.  A.)  Diss,  sur  Ie  croup  aigu  des  enfans.     Par.  1802.  8vo. 
1808.  Recueil  des  obs.  et  des  faits  relatifs  au  croup,  redige  par  lafaculte  de  med. 

Paris.  8vo. 
1808.  Portal    (Ant.)   De   l'Angine   meinbraneuse    (Mem.   sur  plusieurs  mal.)— > 

Par.  8vo. 
1808.  Caron  (J.  C.  F.)     Traite  du  croup  aigu.     Par.  1808.  8vo. 
1808.  Id.     Examen  du  recueil  des  faits  relatifs  au  croup.     Par.  1808.  8vo. 
1808.  Friedlander   (M.)  Samml.  von  beobachtungen  die  d.  hautige  braune  bet- 

reffen.      Tub.  1808.  8vo. 
1808.  HopfF  (J.  W.)  Abhandlung  ueber  das  croup,  &c.     Hanau.  1808.  8vo. 

1808.  Wolf  (W.  L.)  Ueber  d.  luftrohren-braune  der  kinder.     Alt.  1808.  8vo. 

1809.  Hecker    (A.  F.)  Von.  d.    entzundung.   im  halse  besonders  angin.  polyp. 

Berl.  8vo. 

1810.  Marcus  (A.  F.)  Ueber  die  natur,  &c.  der  hautigen  braune.     Bamb.  8vo. 
1810.  Jurine  (L.)  Memoire  sur  le  croup  qui  a  partage  le  prix,  &c.  Genev.  8vo. 

1810.  Cheyne  (J.,  M.D.)  The  pathol.  of  the  memb.  of  the  larynx  and  bronchia. 

Ed.  8vo. 

1811.  Loebenstein-Loebel   (E.)  Erkennt.  und   heilung  der   hautige  braune. — 

Leipz.  8vo. 
1811.  Double  (F.  J.)  Traite  du  croup.  Par.  1811.  8vo. 
1811.  Geraudi  (C.)  D  l'angine  tracheale  ou  croup.  Par.  1811.  8vo. 
1811.  Routte  (F.)  Traite  de  l'asphyxie  connue  sous  le  nom  de  croup.  Par.  8vo. 

1811.  Hosack  (D.  M.D.)  Obs.  on  the  croup  or  hives.     New  York.  1811.  8vo. 

1812.  Eccard   (A.  W.)  Beoiachtungen  &c.  der  hautige  braune.  Nurnb.  1812. 

8vo. 
1812.   Vieusseux  (G.)  Memoire  sur  le  croup  ou  angine  tracheale.   Geneve.  1812. 
8vo> 


140  BRONCHIAL    HEMORRHAGE. 

of  this  practice,  even  in  a  very  striking  degree,  cannot  be  ques- 
tioned in  many  other  inflammatory  diseases,  particularly  hepatitis 
and  peritonitis.  Still  the  success  of  even  the  mercurial  treat- 
ment is  not  sufficiently  great  to  hinder  us  from  looking  for  other 
means ;  and  if  I  had  had  occasion  to  treat  this  disease  since  I 
have  experienced  the  efficacy  of  emetic  tartar  in  large  doses  in 
many  inflammatory  diseases,  I  would  certainly  have  had  recourse 
to  it  with  considerable  confidence.* 


CHAPTER  IV. 

OF    BRONCHIAL    HEMORRHAGE. 

By  this  term  I  wish  to  designate  that  kind  of  spitting  of  blood, 
which  consists  in  simple  exhalation  from  the  surface  of  the  bron- 
chial membrane.  Haemoptysis  was  attributed  by  the  ancients  to 
rupture  of  the  vessels  of  the  lungs ;  and  this  opinion,  which  is 

1812.  Caillau  (J.  M.)  Memoire  sur  le  croup.  Bordeaux.  1812,  8vo. 

1812.  Bonnafox  de  Malet  (J.)  Memoire  sur  le  croup.  Par.  1812.  8vo. 

1812.  Valentin  (L.)  Recherches  historiques  etpractiques  sur  la  croup.  Par.  8vo. 

1812.  Royer-Collard   (A.   A.)   Rapport  sur  les   ouvr.   envoyee  au    cone,  sur  le 

croup.  Par.  1812.  8vo. 

1813.  Rubini  (P.)  Riflessioni  sulla  malattia  denominata  crup.  Parma.  8vo. 
1813.  Routte  (F.)  Doutes  sur  l'existence  du  croup  essentille.  Par.  1813.  8vo. 
1813.  Royer-Collard  (A.  A.)  Diet,  des  Sc.  Med.  (Art.  Croup.)  t.  7.  Par.  1813. 

1815.  Erschenmayer  (L.  A.)  Die  epidemie  des  croups  zu  Kirchheim.  Tub.  Svo. 

1816.  Albers  (J.  A.,M.  D.)  Commentatio  de  tracheilide  infantum.  Leipz.  8vo. 
1820.  Eggert  (F.  F.  S.)  Ueber  das  wesen  und  die  heilung  des  croups.  Ham.  8vo. 
1823.  Guersent.  Diet,  de  Med.  (Art.  Croup.)  t.  6.  Par.  1833. 

1823.  Blaud   (P.)  Nouvelles  rescherches  sur  la  lanngo-tracheite  ou  croup.  Par. 

8vo. 
1826.  Bretonneau  (P.)  Des  inflammations  specials  du  tissu  muqueux,   &c.   Par. 

8vo. 

1826.  Porter  (W.  H.)  Observations  on  the  surgical  pathology  of  the  larynx  and 

trachea.' Z)w6.  1826.  8vo. 

1827.  Desruelles  (H.  M.  J.)  Trait6  theorique  et  pratique  du  croup.  Par.  8vo. 

1827.  Emangard  (E.  P.)  Traite  practique  du  croup.  Par.  1827. 

1828.  Id.  Memoire  additionel  au  traite  du  croup.  Par.  1828. 
1828.  Sachse.  Encyel.  Worterb.  (Art.  Angina.)  B.  2.  Berlin,  1828. 

1830.  Duges  (Ant.)  Diet,  de  med.  et  de  chir.  prat.  (Art.  Croup.)  t.  5.  Par.  1830. 
1833.  Cheyne  (J.,  M.  D.)  Cycl.  of  pract.  med.  (Art.  Croup.)  Vol.  i.  Lond.  1833. 
1833.  Copland  (J.,  M.  D.)  Diet,  of  pract.  med.  (Art.  Croup.)  Lond.  1833. 

*  iiru       t  Transl. 

When  Laennec  wrote  this  chapter,  very  few  facts  had  been  published  in 
relation  to  the  advantages  of  tracheotomy  in  croup  :  and  this  operation  practised 
only  at  long  intervals  and  in  children  who  weje  moribund,  succeeded  so  badly, 
that  practitioners  had  for  the  most  part  abandoned  it.  At  the  present  day! 
however,  a  more  favorable  opinion  of  the  operation  prevails ;  and  science  is' 
indebted  to  Dr.  Trousseau  for  proof  that  tracheotomy  when  practised  early  in 
cases  of  croup,  may  be  perfectly  successful,  and  thus  children  may  be  rescued 
from  death,  which  formerly  mig'ht  be  considered  almost  inevitable.^.4ndrai. 


BRONCHIAL    HAEMORRHAGE.  141  ' 

that  of  the  vulgar,  is  perhaps  still  held  by  certain  physicians  who 
make  a  point  of  never  admitting  any  new  doctrines  until  they  are 
so  generally  received  as  to  demand  their  assent  whether  they  will 
or  no,  and  without  examination.  Be  this  as  it  may,  the  theory 
in  question,  if  adopted  without  sufficient  proof,  has  been  perhaps 
with  as  little  reason  abandoned,  since  the  phenomena  of  exhala- 
tion, in  health  and  disease,  have  been  better  understood.  It  is 
not  impossible  that  an  aneurism  of  one  of  the  branches  of  the 
pulmonary  artery,  or  a  varix  of  the  veins,  may,  by  rupture,  give 
occasion  to  haemorrhage,  although  no  well  described  instance  of 
the  kind  has  come  to  my  knowledge.  When  softened  tubercles 
burst  into  the  bronchi,  the  slight  haemorrhages  that  accompany 
this  accident,  arise,  no  doubt,  from  the  rupture  of  small  vessels ; 
and  we  shall  find  hereafter  that  losses  of  blood  of  much  greater 
consequence,  and  even  mortal,  may  result  from  the  rupture  of 
a  vessel  traversing  a  tuberculous  excavation.  Other  instances  of 
fatal  haemoptysis  arising  from  the  rupture  of  a  vessel,  are  afforded 
by  aneurisms  opening  into  the  trachea,  bronchi,  or  substance  of 
the  lungs.  However,  it  can  no  longer  admit  of  question,  in  the 
present,  state  of  medical  knowledge,  that  the  greater  number  of 
cases  of  slight  or  moderate  haemoptysis,  consists  in  the  simple  ex- 
halation of  blood  from  the  bronchial  membrane  ;  while  the  severe 
cases  originate  chiefly  in  the  vesicular  structure  of  the  lungs,  and 
constitute  the  affection  which  will  be  noticed  hereafter  under  the 
name  of  Pulmonary  Apoplexy.* 

Anatomical  characters. — On  examining  subjects  who  have  died 
of  bronchial  haemorrhage,  or  while  laboring  under  it,  more  or 
less  of  coagulated  or  fluid  blood  is  found  in  the  bronchi.  On  the 
surface  of  the  coagula,  we  sometimes  observe  fibrinous  concre- 
tions in  the  form  of  polypi.  The  mucous  membrane  is  commonly 
a  little  softened,  and  is  impregnated  or  tinged  with  blood  through 
its  whole  depth. 

Signs  and  symptoms. — The  discharge  is  small  or  at  most  mo- 
derate, and  the  blood  is  frothy,  and  sometimes  clotted,  particu- 
larly towards  the  end  of  the  attack.  Those  profuse  haemorrh- 
ages, which  are  vulgarly  called  vomitings  of  blood,  arise  almost 
always  from  pulmonary  apoplexy.  On  this  account,  the  small- 
ness  of  the  discharge,  in  any  case,  may  be  considered  as  affording 
a  strong  probability  that  the  haemoptysis  is  the  result  of  simple 
exhalation.     The  absence  of  the  stethoscopic  signs  of  pulmonary 

*  It  appears  to  me  by  no  means  proved,  that  these  profuse  hasmoptyses  which 
often  occur  in  individuals  whose  lungs  are  tuberculous,  are  caused  by  the  lesion 
described  by  Laennec  under  the  name  of  pulmonary  apoplexy.  I  have  repeat- 
edly dissected  the  bodies  of  subjects  who  had  died  during  one  of  those  hae- 
morrhages, without  finding  any  trace  of  pulmonary  apoplexy.  I  am  of  the 
opinion  that  these  haemorrhages  may  often  arise  from  a  rupture  of  a  blood  ves- 
sel situated  in  a  mass  of  tubercles. — Andral. 


142  BRONCHIAL    HEMORRHAGE. 

apoplexy,  adds  greatly  to  the  certainty  of  our  diagnosis.  Tn  the 
bronchial  haemorrhage,  the  chest  is  perfectly  sonorous.  There 
exists  no  crepitous  rhonchus  ;  but  only  a  mucous  rhonchus  with 
unequal  bubbles,  which  are  usually  larger  than  those  of  catarrh, 
and  seem  to  be  formed  by  more  liquid  materials,  and  to  burst 
more  frequently.  The  rhonchus  is  more  or  less  abundant  ac- 
cording to  the  quantity  of  blood  effused.  When  the  haemorrhage 
is  slight,  there  is  no  general  disturbance  of  the  constitution  per- 
ceptible ;  even  the  pulse  continues  natural.  When  the  haemop- 
tysis is  more  considerable,  it  is  attended  by  a  distinct  febrile 
state ;  the  pulse  becomes  frequent,  and  exhibits  a  vibratory  cha- 
racter, independent  of  either  its  force  or  frequency. 

Occasional  causes. — These  are  such  as  produce  general  ple- 
thora, or  local  conjestions  of  blood  in  the  lungs :  such  as  the 
abuse  of  spirituous  liquors,  excessive  exertion,  particularly  of 
the  organs  of  respiration  and  speech,  suppression  of  an  habitual 
haemorrhage,  the  presence  of  numerous  crude  tubercles  in  the 
lungs.  We  frequently  find  haemoptysis  vicarious  of  the  menses, 
and  recurring  with  considerable  regularity ;  and  discharges  of 
this  kind  have  been  known  to  last  thirty  and  even  forty  years.* 
Suppression  of  the  haemorrhoidal  discharge  appears  to  me   much 

*  Tulpius  lib.  ii.  cap.  ii. — Nov.  Act.  Nat.  Cur.  vol.  i.  obs.  1. 

It  is  not  so  common  as  one  would  suppose  from  this  remark,  to  see  haemop- 
tysis vicarious  of  the  menses,  and  like  them,  occur  every  month  at  uniform 
intervals:  the  frequency  of  such  cases  has  been  strangely  exaggerated.  For 
my  part,  on  almost  every  occasion  that  I  have  seen  women  expectorating  blood 
at  the  period  of  menstruation.  I  have  been  certain  they  had  tubercles  in  the 
lungs.  Their  periodical  haemoptyses  could  not  be  regarded  as  supplementary 
haemorrhages,  but  were  connected  with  the  existence  of  tubercles,  and  their 
occurrence  depended  doubtless  on  the  more  active  congestion  which  took  place 
in  the  lungs  around  the  tubercular  masses. 

The  observation  of  Tulpius,  quoted  by  Laennec,  furnishes  by  no  means  an 
example  of  one  of  these  periodical  haemoptyses.  It  is  a  case  of. a  painter,  who 
had  for  30  years  frequent  attacks  of  raising  blood  without  any  serious  conse- 
quences. The  following  is  the  observation  : — Pictor  Rychius,  obnoxius  a  puero 
acri  ac  salsae  distillationi,  expuit  plurimum  sanguinis  annos  any)lius  triginta  ;  in 
quibus  tamen  licuit  ipsi,  modd  in  Britanniam  trajicere,  modo  vero  in  Ilispaniam 
ac  Galliam  iter  facere.  In  connection  with  this  observation,  Tulpius  cites  an- 
other case  of  an  individual  who  expectorated  blood  with  impunity  for  twenty 
years,  at  the  end  of  which  he  died  of  phthisis.  Such  cases  are  not  uncommon. 
but  the  individuals  are  commonly  valetudinarians  who  are  always  suffering  in 
the  chest,  and  they  generally  die  of  some  pulmonary  disease.  Many  observa- 
tions of  this  sort  may  be  found  in  my  CUnique Medicate.  I  was  lately  consulted 
by  an  old  man  of  eighty,  who  told  me  that  for  more  than  sixtv  years  he  had 
hardly  passed  a  single  year  without  spitting  bjood  more  or  less,  but  in  no  "reat 
quantities  at  a  time.  In  the  intervals  he  was  apt  to  take  cold  ;  his  breathing 
had  been  short  from  childhood,  and  three  or  four  times  he  had  been  attacked 
by  catarrhal  fevers,  which,  he  informed  me,  he  had  recovered  from  with  much 
difficulty.  By  auscultating  his  chest,  I  could  discover  nothing  but  the  rhonchus 
of  bronchitis:  but  a  circumstance  not  the  least  interesting  is,  that  he  had  had 
three  children  who  all  died  young  of  pulmonary  affections,  while  his  wife  did 
not  exhibit  the  least  indication  of  disease  of  this  class.—  Andral. 


BRONCHIAL    HEMORRHAGE.  143 

more  frequently  to  give  rise  to  pulmonary  apoplexy.*  Epileptics 
and  other  subjects  of  strong  convulsions  frequently  discharge  a 
bloody  froth  by  the  mouth.  In  these  cases,  the  blood  comes  no 
doubt  partly  from  the  bronchial  membrane,  but  also  partly  from 
the  lining  membrane  of  the  mouth.  The  bronchi  of  a  great 
many  subjects,  dead  of  different  diseases,  are  found  covered  here 
and  there  with  blood,  evidently  exhaled  in  the  last  moments  of 
life ;  in  like  manner  as  the  pulmonary  congestions  occurring  after 
death,  which  we  shall  notice  hereafter. 

Treatment. — This  consists  most  commonly  in  the  more  or  less 
repeated  use  of  blood-letting.  Taking  blood  from  the  foot  is 
generally  preferable  in  women  when  there  is  suppression  of  the 
catamenia.  When  the  detraction  of  much  blood  is  not  requisite, 
the  application  of  leeches  to  the  inner  side  of  the  thighs  or  below 
the  ancles,  may  be  substituted.  I  give  these  places  the  prefer- 
ence to  the  vulva,  from'  various  reasons  ;  and  among  others,  be- 
cause I  am  convinced  from  many  comparative  trials,  that  leech- 
ing from  the  last-mentioned  place  is  not  more  effective  as  a  de- 
rivative, than  from  the  other  two,  particularly  if  the  blood  is  taken 
from  both  at  the  same  time.f  Dry  cupping  or  with  lancets,  si- 
napisms, stimulating  foot-baths,  may  be  usefully  employed  after 
venesection,  or  in  cases  where  this  is  not  necessary. 

Rest  and  absolute  silence,  a  cool  air,  abstinence  from  wine  and 
stimulant  food,  and  a  regimen  proportioned  in  strictness  to  the 
severity  and  extent  of  the  haemorrhage,  are  accessory  measures 
by  no  means  to  be  neglected.  The  same  remark  applies  to  the 
use  of  mucilaginous  drinks,  such  as' decoction  of  comfrey-root  or 
marsh  mallow,  rice  water,  solution  of  gum  arabic  or  tragacanth, 
&c.J  Acids  and  astringents  are  also  commonly  employed,  par- 
ticularly Veau  de  Rabel,§  or  the  sulphuric  acid  sufficiently  diluted, 
alum,  tormentilla,  bistort,  kino,  or  pomegranate  bark,  and,  of  late, 

*  This  assertion  is  at  least  doubtful.  The  number  of  cases  in  which  a  haemop- 
tysis lias  been  known  to  arise  from  the  suppression  of  a  hsemorrhoidal  discharge 
is  also  much  smaller  than  has  been  stated.  For  my  part  !  do  not  think  it  has 
been  proved  that  pulmonary  apoplexy  in  particular  has  ever  been  occasioned  by 
such  a  cause. — An&ral. 

t  If  it  be  desired  simply  to  determine  a  derivative  effect,  I  agree  with  Laen- 
nec.  But  if  the  object  be,  at  the  same  time,  to  determine  towards  the  uterus  a 
flow  of  blood  which  shall  bring  on  the  menses  hitherto  suppressed,  I  think  the 
end  may  be  attained  with  more  certainty  by  applying  every  month  for  three  or 
tour  days  in  succession,  a  couple  of  leeches  to  the  inner  surface  of  the  external 
labia. — Andral. 

\  These  latter  measures,  as  indeed  the  common  usage  of  practitioners,  are  in 
direct  opposition  to  the  principle  of  cure  so  much  insisted  on  by  Mr.  Davidson 
in  his  "  Observations  on  the  Pulmonary  System."  viz.  that  of  withholding 
every  kind  of  fluid.  But  it  is  evident  that  this  practice  is  founded  on  a  miscon- 
ception of  the  physiology  of  nutrition  in  respect  of  liquids. —  Transl. 

§  Aqua  Rabdliana,  so  named  from  its  inventor,  the  empiric  Rabel :  it  is 
formed  of  three  parts  alcohol  and  one  part  sulphuric  acid,  and  constitutes  a  sort 
of  sulphuric  ether. —  Transl. 


144  BRONCHIAL  MEMBRANE. 

rhatany  root  pnd  its  extract.  These  means  are  more  hurtful  than 
beneficial  at  the  commencement  of  the  haemorrhage ;  but  they 
may  sometimes  be  advantageously  employed  in  old  cases,  which 
are  combined  with  an  atonic  state  of  the  system,  or  when  the 
blood  is  only  slightly  colored  and  feebly  concrescible.  In  this 
last  case  I  have  sometimes  used  with  benefit  the  dry  sulphate  of 
iron.  To  derive  advantage  from  astringents  they  must  be  given 
in  larger  doses  than  is  usual.  I  give,  for  example,  from  one  to 
four  drachms  of  alum  in  a  pint  of  any  sweet  mucilaginous 
drink.* 

When  an  active  haemoptysis  is  checked,  Sydenham  advises  the 
patient  to  be  purged,  and  looks  upon  this  means  as  most  likely 
to  prevent  a  relapse.  I  have  always  adopted  the  same  practice, 
(except  when  evidently  contra-indicated,)  and,  as  it  appeared, 
frequently  with  advantage.  Obstinate  spittings  of  blood,  which 
have  resisted  repeated  bleedings,  sometimes  terminate  instanta- 
neously under  the  effect  of  a  purgative. 


CHAPTER  V. 


POLYPUS    OR    THE    BRONCHIAL    MEMBRANE. 

This  is  a  very  rare  affection.  I  have  only  met  with  three  ex- 
amples of  it  on  record.f  These  appeared  to  be  of  the  same  na- 
ture as  the  vesicular  polypi  of  the  nostrils,  ears,  and  os  uteri,  that 
is  to  say,  of  a  texture  analogous  to  that  of  the  mucous  mem- 
branes, and  containing  small  serous  cysts.  I  lately  met  with  a 
concretion  in  one  of  the  large  bronchi  of,  a  phthisical  subject, 
which  might  have  been  easily  mistaken  for  a  polypus.  It  was 
about  an  inch  and  a  half  long,  and  from  four  to  five  lines  thick, 
and  almost  entirely  filled  the  canal  in  which  it  lay.  It  adhered 
closely  to  the  angle  formed  by  the  union  of  the  two  larger  bron- 
chi, and  although  it  lay  in  the  left,  in  the  fits  of  coughing  its 
movable  extremity  plugged  up  the  opening  of  the  right  branch, 
and  occasioned  at  the  time  imminent  suffocation.  It  is  remark- 
able, however,  that  although  it  plugged  up  almost  entirely  the 
left  branch,  insomuch  as  to  leave  not  more  than  half  a  line  of 
space  for  the  passage  of  the  air,  it  neither  impeded  respiration 
on  this  side,  nor  prevented  the  manifestation  of  pectoriloquy  in 

*  A-saturated  solution  of  alum  has  recently  been  strongly  recommended  by 
Dr.  Scudamore,  as  a  styptic.     See  his  work  on  the  blood,  p.  161.—  Transl 

\  Murray.  Nov.  Comm.  Gcetting.  IV.  U.—  Ckcync,  Ed.  Med.  and  Surg.  Journ. 
IV.     Horn.  Archiv.  1811,  Jan.  p   176 


BRONCHIAL  MEMBRANE.  145 

a  cavity  in  the  upper  lobe.*  The  texture  of  this  concretion  was 
compact  and  perfectly  resembled  the  polypus-like  concretions 
found  in  the  heart  and  arteries,  except  that  it  was  much  firmer 
and  drier,  having  evidently  undergone  incipient  organization.  It 
was  white,  with  some  shades  of  yellow  and  red,  internally ;  and 
contained  some  small  blood-vessels  well  formed  and  finely  branch- 
ed. Externally  it  was  of  a  pretty  deep  violet  red  color,  and  still 
more  distinctly  vascular.  This  concretion  was  no  doubt  the  re- 
mains of  a  coagulum  of  blood  which  had  been  left  in  the  bron- 
chial cavity,  after  an  attack  of  haemoptysis,  of  which  the  patient 
had  had  several.  Many  other  facts  prove  the  possibility  of  the 
organization  of  fibrine  when  separated  from  the  blood ;  and  I 
shall  myself  have  occasion  to  notice  several  of  the  kind,  when 
treating  of  diseases  of  the  organs  of  circulation.  The  fleshy 
uterine  moles  are  of  the  same  origin  and  character  ;  only  they 
approach,  in  appearance  and  consistence,  nearly  to  fibrous  tex- 
tures.! I  am  also  of  opinion  that  those  pieces  of  flesh,  which 
some  of  the  older  authors  state  to  have  been  expectorated,  were 
derived  from  this  source.;];  This  is  evidently  the  case  in  those 
instances  recorded  by  them  in  which  the  flesh  was  discharged 
during  or  subsequent  to  severe  haemoptysis,^  or  where  the  con- 
cretions expectorated  were  of  the  form  of  a  pulmonary  vessel.  || 

*  Reveuc  Medicale,  Mars  1824,  p.  384. 

t  I  have  sometimes  found  the  bronchi  obstructed  by  concretions  of  a  nature 
different  from  that  described  here  by  Laennec.  They  consisted,  not  of  coagu- 
lated blood,  but  of  concrete  and  hardened  mucus.  On  this  subject,  see  my 
Clinique  Medicale  torn.  3.  p.  22'2.  3d  edition. — Andral. 

X  Act.  Nat.  Cur.  vol.  v.  obs.  Ixxiv. 

§  Comm.  Litt.  Norimb.  1745,  p.  215. 

||  Act.  Nat.  Cur.  vol.  vii.  obs.  xliv. — Tohn  in  Act.  Erud.  1683.  In  this'short 
chapter  our  author  seems  hardly  to  retain  his  accustomed  correctness  and  clear- 
ness. He  evidently  confounds  very  different  diseases  under  the  same  appella- 
tion. The  true  polypus  of  the  bronchi,  I  mean  of  the  same  kind  as  the  chronic 
growth  of  the  nose,  os  uteri,  and  other  mucous  membranes,  is  no  doubt  an  ex- 
tremely rare  disease  ;  and  M.  Laennec  commits  a  great  mistake  in  ranking  the 
case  of  Dr.  Cheyne,  as  of  this  kind.  It  was  an  inorganized  concretion  analogous 
to  that  of  croup,  the  result,  no  doubt,  of  a  chronic  inflammation  of  the  bronchial 
membrane.  Another  variety  of  the  bronchial  polypus  is  that  which  follows 
haemoptysis,  and  seems  to  be  precisely  of  the  kind  described  in  the  text  as  "  a 
concretion  found  in  a  phthisical  subject."  For  various  examples  of  both  these 
kinds,  see  Cheyne's  Pathology  of  the  Larynx  and  Bronchia,  p.  147. —  Transl. 


19 


|46  ULCERS    OF    THE    BRONCHI. 

CHAPTER  VI. 

ULCERS    OF    THE    BRONCHI. 

Ulceration  of  the  bronchi  is  an  extremely  rare  affection  ;  al- 
though it  would  perhaps  be  less  so  if  we  were  more  in  the  habit 
of  examining  the  bronchi  carefully  and  minutely.  In  this  case,  it 
is  probable  that  we  should  occasionally  find  in  phthisical  subjects, 
in  those  more  particularly  where  there  existed  a  like  affection  of 
the  larynx,  ulcers  of  the  mucous  membrane  of  the  bronchi,*  the 
consequence  of  the  small  tubercles  which  now  and  then  form  in 
this  membrane.  The  part  of  the  bronchial  membrane  in  which 
ulceration  has  been  most  frequently  observed,  is  that  comprised 
between  the  point  where  the  trachea  enters  the  thorax,  and  the 
bifurcation  of  the  bronchi.  M.  Cayol  was  the  first  who  gave  an 
exact  description  of  this  affection,  of  which  nothing  was  previ- 
ously known,  besides  some  examples  noticed  by  Morgagni.f 

Anatomical  characters. — The  size  of  the  ulcers  varies  from  a 
few  lines  to  an  inch  and  a  half.  They  are  of  a  greyish  dirty  co- 
lor, covered  with  a  puriform  mucus,  generally  in  considerable 
quantity,  with  edges  somewhat  swollen  and  marked  by  a  redness 
which  extends  to  some  distance  around  ;  and  the  bronchial  rings 
and  the  muscular  and  ligamentous  substance  uniting  these,  are 
sometimes  of  the  same  color  throughout.  They  are  rarely  met 
with  beyond  the  bifurcation  of  the  bronchi. 

Andral   relates  three  cases  of  ulceration  of  the  bronchi.J     In 

*  M.  Louis's  laborious  and  most  minute  researches  have  proved  the  correct- 
ness of  M.  Laennec's  conjecture.  Of  one  hundred  and  two  phthisical  subjects, 
the  trachea  was  found  ulcerated  in  thirty-one,  the  larynx  in  twenty-two,-  and 
the  epiglottis  in  eighteen.  In  the  whole  of  his  researches  he  only  met  with  sev- 
en cases  of  ulceration  of  the  bronchi ;  but  he  adds,  that  this  may  have  been 
somewhat  more  frequent,  as  he  did  not  always  examine  the  bronchi  with  the 
same  care  as  the  trachea.  See  his  Recherches  stir  la  Phthisic,  p.  44.  It  would, 
however,  appear  from  Dr.  Hasting's  observations,  that  ulceration  of  the  bronchi 
is  of  much  more  frequent  occurrence  than  even  Louis  supposes.  In  his  account 
of  chronic  bronchitis  he  says — "  It  is  not  at  all  common  to  find  this  membrane 
ulcerated.  This  happens  more  particularly  when  the  disease  has  arisen  from 
the  irritation  of  mechanical  substances.  The  ulcers  are  always  superfi- 
cial and  generally  small ;  but  occasionally  in  the  larger  bronchial  cells  they  are 
of  considerable  magnitude,  and  oblong  or  oval  in  shape.  In  the  leather  dressers 
of  this  town  (Worcester)  who  died  of  chronic  bronchitis,  the  mucous  membrane 
is,  according  to  the  observation  of  the  author,  always  ulcerated,  and  in  those  in- 
stances he  has  seen  more  extensive  ulceration  than  in  any  other."  Treatise  on 
Inflammation  of  the  Mucous  Membrane  of  the  Lungs,  p.  281.  See  also  cases  !. 
2,  5,  8,  10, 11,  14,  15,  18,  21,  22  ;  in  all  of  which  ulceration  of  the  bronchial 
membrane  is  mentioned. —  Transl. 

t  Recherches  sur  la  Phthisic  Tracheale,  Paris,  1810.— De  Sed.  et  Caus.  L.  ii. 
Ep.  15. 

X  Clinique  Med.  torn.  ii.  p.  7. 


ULCERS    OF    THE    BRONCHI.  147 

the  first,  as  in  the  cases  of  M.  Cayol,  the-  ulcers  were  near  the 
bifurcation  of  the  bronchi ;  in  the  second  they  existed  in  the 
small  bronchial  branches.  In  this  last  instance,  the  ulcerations, 
of  the  size  of  a  millet  seed,  were  circular  and  with  livid  and  tu- 
mid borders.  The  patient  had  been  distressed  by  frequent  and 
very  painful  fits  of  coughing;  and  his  expectoration  was  usually 
tinged  with  blood.  He  died  of  aneurism  of  the  heart.  In  the 
third  case,  the  trachea  from  its  origin  to  a  little  above  its  bifur- 
cation, was  literally  like  a  sieve  from  an  immense  quantity  of  mi- 
nute ulcers,  so  numerous  and  close  indeed,  that  the  space  oc- 
cupied by  them  was  greater  than  the  sound  portion  of  the 
membrane.  This  disease  had  been  attended  by  a  sensation  of 
habitual  heat,  rather  than  pain,  in  the  trachea;  and  inspiration 
was  accompanied  by  a  remarkable  hissing,  occasioned  probably 
by  the  continual  tendency  of  the  glottis  to  descend,  on  account  of 
the  irritation  produced  by  the  passage  of  the  air.  I  know  of  no 
instance  of  complete  perforation  of  a  bronchial  trunk,  from  ulcer- 
ation, before  entering  the  lungs.  The  author  just  quoted  re- 
lates two  cases  of  perforation  of  the  trachea  from  this  cause.  In 
the  one,  the  ulcer  opened  into  the  oesophagus,  and  was  produc- 
tive of  no  further  inconvenience  than  a  little  uneasiness  and  cough 
when  the  patient  swallowed  ;  in  the  other,  the  opening  was  in  the 
back  part  of  the  trachea  ;  but  it  must  have  been  either  incom- 
plete, or  its  edges  must  have  been  united  to  the  neighboring 
parts,  as  there  appears  not  to  have  been  any  emphysema  around 
it. 

Symptoms.  These  are — a  pain,  at  first  slight,  or  a  simple 
feeling  of  irritation  at  the  bottom  of  the  trachea,  experienced 
momentarily,  and  sometimes  only  when  the  patient  sings,  cries,  or 
raises  the  voice  in  speaking.  This  state  may  continue  a  long 
time.  I  know  a  lady  who  has  suffered  in  this  way  for  ten  years, 
without  any  other  apparent  alteration  in  her  health.  She  had 
tried  various  means,  and  particularly  the  most  powerful  issues, 
without  effect,  and  has  only  found  relief  in  preserving  absolute 
silence.  After  a  time,  the  pain  becomes  constant,  even  when  the 
patient  is  silent ;  and  even  then  it  is  found  that  the  voice  is  not 
always  perceptibly  altered  in  its  character.  Cough  soon  super- 
venes, attended  by  a  colorless,  ropy,  pituitous  expectoration, 
intermixed  with  opaque  puriform  particles.  When  this  becomes 
abundant,  a  rhonchus,  perceptible  by  the  naked  ear,  is  heard  in 
the  trachea  ;  and  when  not  so  heard,  I  have  found  it  very  dis- 
tinct by  means  of  the  stethoscope.  This  instrument  detected  it 
at  the  same  time  in  various  parts  of  the  lungs,  while  in  many 
points  it  discovered  the  respiration  to  be  very  feeble.  This  was 
owing  probably  to  the  accumulation  of  phlegm  in  the  smaller 
bronchi,  since  the  respiration  became  good  after  expectoration. 


148  ULCERS  OF  THE  BRONCHI. 

These  symptoms  are  soon  accompanied  by  extreme  dyspnoea,  the 
patient  being  obliged  to  remain  in  the  sitting  posture  night  and 
day  ;  and  when  he  awakes  after  an  imperfect  sleep  he  is  apt  to 
be  seized  with  a  suffocating  cough,  as  if  some  foreign  body  had 
got  into  the  trachea  ;  and  this  continues  until  after  the  expecto- 
ration of  a  certain  quantity  of  mucus.  At  this  stage,  emaciation, 
which  had  hitherto  been  slow  in  its  progress,  makes  rapid  ad- 
vances, and  sometimes  produces  extreme  extenuation ;  and  the 
patient  at  last  dies  with  all  the  symptoms  of  the  suffocative  ca- 
tarrh. 

Very  great  efforts  of  voice,  acute  cries,  violent  forcing  of  the 
head  backwards,  have  sometimes  appeared  to  be  the  occasional 
cause  of  the  ulcers  of  the  trachea.  Cutaneous  complaints  and 
syphilis  would  seem  also  to  predispose  to  them.  Although  some- 
times met  with  in  phthisical  cases,  they  are  found  more  commonly 
in  subjects  whose  lungs  are  entirely  sound.*  We  must,  however, 
except  those  cases  where  ulceration  of  the  trachea  or  upper  part 
of  the  bronchi  is  occasioned  by  the  rupture  of  softened  tuber- 
cles situated  in  one  of  the  cervical  or  bronchial  glands.  But  ul- 
cers of  this  kind  cannot  be  considered  as  at  all  of  an  idiopathic 
nature,  being  entirely  analogous  to  those  fistulous  openings  pro- 
duced by  the  discharge  of  a  tubercle,  abscess,  or  gangrenous  es- 
char of  the  lungs,  into  the  branches  of  the  bronchi.  Ulcers  of 
this  kind  have  a  great  tendency  to  cicatrization,  and  are  found 
after  a  certain  time,  smooth,  polished,  and  without  any  appearance 
of  spreading.  The  tracheal  ulcer,  on  the  contrary,  appears  to 
have  no  tendency  to  cicatrize,  and  I  know  of  no  well  authenticated 
instance  of  the  cure  of  this  affection. 

Treatment.  The  most  obvious  indication  in  this  case  is,  un- 
questionably, the  employment  of  local  drains ;  and  the  most  ac- 
tive ought  to  be  had  recourse  to.  Blisters  and  issues  applied  at 
a  distance  from  the  affected  part,  have  never  appeared  to  me  of 
any  use.  What  I  have  found  most  benefit  from,  is  the  repeated 
application  of  small  moxas  on  the  anterior  and  lower  part  of  the 
neck,  and  the  preservation  of  absolute  silence  by  the  patient. 

*  This  remark  of  our  author  appears,  from  the  researches  of  Louis,  already 
quoted,  to  be  incorrect.  He  says — "  In  comparing  the  state  of  the  epiglottis,  la- 
rynx, and  trachea,  in  persons  dead  of  other  diseases  (chiefly  chronic)  beside 
phthisis,  I  have  only  found  among  one  hundred  and  eighty  cases,  one  ucleration 
of  the  larynx,  and  two  others  of  the  larynx  and  trachea  conjointly.  In  the  first 
case  the  patient  died  of  peripneumony,  and  in  the  two  last  the  fatal  disease  was 
cancer  or  softening  of  the  brain,  but  there  were  found  tuberculous  excavations 
in  the  lungs."  When  this  statement  is  compared  with  that  in  the  preceding 
note  we  seem  justified  in  concluding,  with  this  author,  in  direct  opposition  to 
M.  Laennec,  "that  ulcerations  of  the  larynx,  and  more  particularly  those  of  the 
trachea  and  epiglottis,  are  peculiar  to  phthisis."     Op.  Cit.  p.  50.—  Transl. 


ALTERATIONS    OF    THE    COATS    OF    THE    BRONCHI.  149 


CHAPTER  VII. 

ALTERATIONS    OF    THE    COATS    OF    THE    BRONCHI. 

The  cartilaginous  rings  of  the  bronchi  become  occasionally  ossi- 
fied in  old  persons,  and  sometimes  even  in  those  less  advanced  in 
life,  and  they  frequently  become  carious  in  tlje  vicinity  of  ulcers. 
The  ossification  is  rarely  complete,  being  commonly  of  the  earthy 
character,  that  is  to  say,  with  predominance  of  the  earthy  base 
of  bone.  In  their  natural  state  the  bronchial  ramifications  have 
no  cartilaginous  rings,  but  they  acquire  this  character  when  di- 
lated and  thickened :  they  may  even  become  entirely  cartilagi- 
nous or  ossified,  and  this  whether  dilated  or  not.  These  degene- 
rations are  rare  and  usually  very  partial ;  and  in  them  the  mu- 
cous membrane  remains  healthy,  surrounded  with  its  bony  or 
cartilaginous  sheath. 

No  perceptible  alteration  in  the  functions  of  the  lungs  is  con- 
nected with  this  condition  of  the  bronchi. 


CHAPTER  VIII. 

OF    FOREIGN    BODIES    IN    THE    BRONCHI. 

Morsels  of  food,  pins,  needles,  pieces  of  wood,  stones  of  fruits 
sometimes  get  into  the  bronchi.  Violent  irritation,  convulsive 
cough,  and,  if  the  foreign  body  is  large,  threatening  suffocation, 
are  the  immediate  consequence  of  this  accident,  which  is,  never- 
theless unattended  by  any  very  pressing  danger,  unless  the  body 
introduced  is  sufficiently  large  to  obstruct,  more  or  less  com- 
pletely, the  larynx  or  trachea.  Cough,  accompanied  by  a  mu- 
cous or  bloody  expectoration,  is  the  most  usual  symptom  which 
supervenes  to  the  accident ;  but  even  this  soon  passes  off",  parti- 
cularly if  the  substance  is  small  and  falls  down  into  a  bronchial 
ramification ;  the  organ  becomes  accustomed  to  the  foreign  body, 
and  no  inconvenience  is  produced  by  it. 

Accidents  of  this  sort  arise  from  very  various  causes.  I  was 
myself  witness  to  a  very  singular  case  of  the  kind.  Professor 
Corvisart  being  desirous  of  exercising  an  unexpected  supervision 
of  some  part  of  the  clinical  hospital,  came  to  it  one  evening  con- 
trary to  his  custom,  and  suddenly  entered  the  apartments  of  the 
steward,  who  had  been  indulging  in  a  too  plentiful  repast.    Taken 


150  OF    FORETON    BOTTES    IN    THE    BRONCHI. 

by  surprise,  the  man  becomes  sick  at  stomach,  but  making  a  vio- 
lent effort  to  repress  vomiting,  he  falls  to  the  ground  and  expires. 
On  examining  the  body,  the  larynx,  trachea,  and  bronchi  are 
found  filled  with  half-digested  food. 

The  ancient  pathologists  regarded  foreign  bodies  introduced 
into  the  bronchi  in  a  state  of  powder,  as  the  cause  of  several 
severe  diseases  of  those  canals,  as  well  as  of  the  substance  of  the 
lungs  ;  and  among  others,  of  phthisis  pulmonalis,  and  the  chalky 
concretions  of  the  Jungs,  bronchial  glands  or  bronchial  tubes. 
This  opinion  appears  to  me  altogether  without  foundation.  It  is 
imao-ined  that  stone-cutters  and  lapidaries  are  particularly  sub- 
ject to  formations  of  this  kind,  occasioned  by  the  inhalation  of 
the  dust  amid  which  they  work. 

It  is  needless  to  remark  that  this  dust  is  entirely  unlike  the 
cretaceous  formations  in  the  lungs.  On  this  subject  it  deserves 
notice  that  stage  coachmen,  who  spend  their  life  amid  much  more 
dust,  are  usually  healthy,  or  suffer  only  from  diseases  produced 
by  intemperance  and  the  inclemency  of  the  weather.  It  is  in- 
deed singular  how  little  sensible  the  mucous  membrane  of  the 
bronchi  is  to  solid  matters  when  reduced  to  an  impalpable  pow- 
der, when  we  know  that  the  introduction  of  a  body  only  a  little 
larger,  such  as  a  bit  of  sugar,  or  even  of  a  gummy  or  albuminous 
fluid,  occasions  extreme  irritation  and  cough.  Every  one  is  oc- 
casionally caught  in  a  cloud  of  dust,  and  merely  experiences, 
while  breathing  in  it,  an  oppression  without  any  inclination  to 
cough.  It  is  well  known  that  when  we  have  been  for  some  time 
breathing  an  air  loaded  with  dust  or  smoke,  those  foreign  bodies 
are  after  a  certain  time  expectorated  with  the  mucous  secretion 
of  the  bronchi.* 

*  There  can  be  no  doubt  of  the  correctness  of  our  author's  opinion  as  far  as 
regards  the  production  of  cretaceous  matters  in  the  lungs;  but  it  does  not  admit 
of  question,  that  the  habitual  inhalation  of  dust  of  various  kinds  is  a  fruitful 
source  of  bronchial  inflammation,  among  artisans,  and  more  especially,  in  this 
country,  needle  grinders,  leather-dressers,  and,  I  can  add  from  my  own  experi- 
ence, miners.  An  immense  proportion  of  the  miners  in  Cornwall  are  destroyed 
by  chronic  bronchitis;  one  of  the  principal,  though  by  no  means  the  sole  cause 
of  which,  I  consider  to  be  the  inhalation  of  dust.  See  Ramazzini  De  Morbis 
Artif.  Diatriba;  also  Ackerman's  German,  and  Patissier's  French  translation, 
with  additions,  of  this  work.  See  also  Dr.  Johnstone's  Paper  on  the  Needle 
Grinder's  Consumption;  Mem.  Med.  Soc.  vol.  v.;  Dr.  Knight's  Paper  on 
Grinder's  Asthma  in  the  North  of  England,  Med.  Journ.  vol.  i. ;  and  Dr.  Dar- 
wall's  Article  on  the  Diseases  of  Artisans,  in  the  Cyc.  of  Pratt.  Med.  and  Mr. 
Thackrah's  treatise  on  the  influence  of  the  Arts  on  Health.  See  also  Dr. 
Hasting's  treatise  already  quoted,  page  273,  and  cases  8,  9,  10,  11,  12.  13,  for 
undoubted  evidence  of  the  powerful  effect  of  the  inhalation  of  dust.  In  page 
300  he  remarks — "  The  leather  dressers  and  the  workers  in  the  china  manufac- 
tories of  this  town  are  very  frequently  affected  in  this  manner.  They  are  re- 
lieved for  a  time  by  medicine  ;  but  the  disease  always  destroys  them  if  they  do 
not  quit  their  employment — Transl. 

About  a  dozen  leagues  from  Blois  in  the  department  of  Loir-et-cher  is  a 
town  called  Meunes,  where  the  greater  part  of  the  inhabitants  are  occupied  in 


BRONCHIAL    GLANDS.  151 

For  these  reasons  I  consider  the  chalky  formations  in  the  bron- 
chi, as  well  as  every  accidental  production  in  the  living  body,  as 
the  result  of  perverted  secretion.  These  productions  in  the 
bronchi  I  have  only  met  with  in  branches  which  are  dilated,  or  in 
the  vicinity  of  old  tuberculous  excavations  cured  by  the  forma- 
tion of  a  Vistula,  or  cartilaginous  cicatrice  ;  and  we  shall  find 
hereafter,  when  treating  of  phthisis,  that  the  development  of  cre- 
taceous matter  frequently  succeeds  that  of  tubercles. 


CHAPTER  IX. 


OF    DISEASES    OF    THE    BRONCHIAL    GLANDS. 

These  glands  differ  from  all  other  lymphatic  glands  in  being,  in 
the  adult,  of  a  deep  black  color,  at  least  in  their  centre,  and 
most  commonly  through  their  whole  substance.  The  coloring 
matter  is  evidently  united  with  the  lymph.  If  a  drop  of  this  is 
applied  to  the  skin  and  permitted  to  dry,  the  black  spot  pro- 
duced is  washed  off  with  difficulty.  This  color  of  the  glands 
must  not  be  considered  as  morbid,  since  it  is  found  in  subjects 
whose  lungs  are  perfectly  sound.  The  coloring  material  is  ob- 
viously the  same  as  the  black  pulmonary  matter  to  be  noticed 
hereafter. 

making  gun-flints.  These  caillouteux,  as  they  are  called,  die  nearly  all  young, 
exhibiting  the  various  symptoms  of  pulmonary  consumption.  This  premature 
mortality  is  believed  at  Meunes  to  be  caused  by  the  workmen  breathing  con- 
stantly the  fine  dust  which  arises  from  the  flint  every  time  it  is  broken  by  the 
instrument.  I  had  occasion  to  open  the  body  of  one  of  these  workmen  who 
died  of  the  disorder  known  in  these  parts  by  the  name  of  maladie  des  caillou- 
teux ;  I  found  the  lungs  full  of  tubercles,  crude  and  soft,  and  ulcerations  in  the 
intestines, — in  a  word,  the  same  kind  of  lesions  commonly  found  in  phthisical 
subjects,  and  nowhere,  either  in  the  bronchi  or  in  the  parenchyma  of  the  lungs 
could  I  find  any  traces  of  the  silicious  matter  which  might  have  been  introduced 
through  the  air  passages.  I  doubt  very  much  whether  the  introduction  of  this 
matter  into  the  bronchi,  is  the  real  cause  of  the  pulmonary  phthisis  which  is 
endemic  among  the  caillouteux  of  M.eunes.  I  have  seen  them  at  work,  and 
have  satisfied  myself  that  the  fine  powder  thrown  off  by  the  fragments  of  flint 
by  no  means  rises  to  their  mouths,  but  falls  by  its  own  weight  to  the  ground. 
On  the  other  hand,  these  workmen  are  constantly  exposed  to  cold  during  win- 
ter, and  what  is  particularly  important  to  remark,  they  pass  entire  days  with  their 
feet  upon  heaps  of  stone  which  are  continually  drawing  from  them  large  quanti- 
ties of  caloric.  All  of  them,  in  consequence,  complain  much  of  their  sufferings 
from  cold  :  they  affirm  that  their  feet  are  constantly  benumbed  by  cold,  and 
that  they  are  affected  with  coughs  and  rheumatic  pains.  Until  further  informa- 
tion, therefore,  I  consider  that  the  cause  of  the  frequency  of  tubercular  con- 
-iimption  among  these  people  should  he  sought  for  in  the  nature  of  the  atmos- 
phenc  influences  to  which  they  are  subjected,  rather  than  in  the  introduction 
to  the  lungs  of  particles  of  silex,  a  phenomenon,  the  reality  of  which  remains 
to  be  proved. — Andral. 


152  BRONCHIAL    GLANDS. 

Inflammation  of  the  bronchial  glands  is  very  little  known,  and 
appears  to  be  very  rare.  In  cases  of  peripneumony  these  glands 
are  pretty  frequently  enlarged,  and  of  a  pale  red  or  slightly 
brownish  hue,  but  not  indurated.  In  a  very  few  instances  only 
have  I  met  with  abscess  in  them.  This  is  the  more  remarkable, 
since  lymphatic  glands  generally  become  affected  from  the  in- 
flammation of  the  organ  with  which  they  are  connected  being 
communicated  to  them. 

There  are  two  kinds  of  accidental  productions  very  commonly 
met  with  in  these  glands,  namely,  cretaceous  matter  and  tuber- 
cles. The  former  is  usually  situated  in  the  centre,  intermixed 
with  the  glandular  substance.  It  is  frequently  so  soft  as  to  be 
forced  out  by  pressure,  and  sometimes  quite  dry  and  hard.  It 
very  rarely  involves  the  whole  structure  of  the  gland.  I  have 
never  seen  it  with  the  character  of  bone.  Most  commonly  it  co- 
exists with  tubercle  ;  in  which  case  it  occupies  the  centre  of  the 
gland,  and  contrasts,  by  its  dull  white  color,  with  the  pale 
yellow  of  the  tuberculous  matter.  Frequently  both  these  sub- 
stances, particularly  the  latter,  are  stained  with  black  bronchial 
matter,  as  if  it  had  been  applied  to  the  surface  of  the  incised 
gland  by  a  pencil  or  crayon.  These  stains  point  out  the  remains 
of  the  original  substance  of  the  gland  amid  the  accidental  pro- 
ductions which  have  usurped  its  place. 

The  tuberculous  matter  is  more  frequently  found  by  itself; 
and  is  sometimes  met  with  in  these  glands,  when  there  are  neither 
tubercles  in  the  lungs  nor  marks  of  any  severe  affection  of  them. 
This  is  particularly  the  case  in  scrophulous  children.  The  tu- 
berculous matter  is  almost  always  disseminated  through  the  sub- 
stance of  the  glands ;  in  very  rare  instances  it  is  collected  in 
isolated  masses.  Glands  affected  in  this  manner  may  reach  the 
size  of  a  pigeon's  or  hen's  egg ;  and  several  are  often  united  in 
one  mass.  These  tubercles  soften  in  two  different  ways, — by 
separating  into  two  portions  like  cheese  and  whey,  (in  scrophu- 
lous subjects,)  and  by  forming  a  thick  flaky  pus.  The  matter 
thus  softened  is  either  carried  off  by  absorption,  or  opens  into  the 
bronchi.  In  this  latter  case,  the  gland  sometimes  remains  exca- 
vated, lined  by  an  adventitious  membrane  like  the  mucous,  and 
forming  one  continuous  surface  with  the  inner  tunic  of  the 
bronchi,  the  opening  into  which  remains  fistulous.  M.  Guersent, 
physician  of  the  Children's  Hospital,  has  met  with  this  case 
pretty  frequently,  and  has  even  known  such  fistulas  to  communi- 
cate with  the  oesophagus.*  They  are  very  much  rarer  in  the 
adult.f 

*  Recherches  sur  une  espece  de  phthisie  particuliere  aux  enfans.  Par  M  Le 
Blond.— Paris,  1824.  * 

*  Calcareous  concretions  formed  in  the  bronchial  glands  may  also  bring  on  an 


BRONCHIAL    GLANDS.  153 

There  can  be  no  doubt  that  these  cavities  in  the  glands  com- 
municating with  the  bronchi,  ought  to  yield  pectoriloquy  ;  but 
owing  to  the  situation,  it  would  be  difficult  to  distinguish  it  from 
bronchophony,  which  I  have  stated  to  be  extremely  distinct,  par- 
ticularly in  children,  at  the  root  of  the  lungs.  If,  however, 
the  phenomenon  were  conjoined  with  a  circumscribed  cavernous 
rhonchus,  the  diagnosis  would  be  nearly  certain.  The  develop- 
ment of  tubercles  in  a  few  of  the  bronchial  glands,  is  of  very 
slight  consequence,  provided  the  lungs  or  cervical  and  mesenteric 
glands  are  free  from  them. 

Treutler,  a  German  physician,  discovered  in  1789,  in  the  bron- 
chial glands  of  a  phthisical  subject,  a  new  species  of  worm,  which 
he  denominated  hamularia  lymphatica,  and  of  which  he  gives 
the  following  description :  "  One  inch  in  length,  of  a  fawn  color, 
spotted  with  white ;  body  slender,  roundish,  flattened  at  the 
sides ;  head  obtuse,  with  two  prominent  small  tentaculae,  be- 
neath."* It  has  not  been  met  with  since.  This  circumstance, 
taken  in  conjunction  with  the  tentaculae,  might  lead  us  to  suppose 
that  this  author  had  mistaken  the  larva  of  some  insect  for 
an  entozootic  worm.  Such  a  mistake  might  readily  enough  hap- 
pen to  a  person  not  particularly  conversant  in  helminthology,  as 
was  Treutler's  case.  In  my  early  life  I  fancy  that  I  committed 
a  similar  mistake,  in  describing  under  the  name  of  distomus  in- 
tersectus,  and  as  a  new  species  of  worm,  an  animalcula  which  one 
of  my  patients  conceived  to  have  passed  by  stool,  but  which  I 
now  strongly  suspect  to  have  been  merely  the  larva  of  some  fly 
accidentally  fallen  into  the  night  chair,  f 

We  are  constantly  observing  in  the  medical  journals  cases 
which  would  lead  us  to  imagine  that  nothing  was  more  common 
than  the  degeneration  of  the  bronchial  glands  into  melanosis. 
When  I  come  to  treat  of  melanosis  of  the  lungs,  this  subject  will 
be  more  particularly  noticed ;  I  shall  here  content  myself  with 
repeating  what  has  been  already  stated,  and  what  has  been  long 
well  known  to  the  anatomists,  that  the  ordinary  color  of  the  bron- 
chial glands  in  the  adult,  is  a  black,  more  or  less  general  and  more 
or  less  deep. 

ulcerative  inflammation  of  the  bronchi  surrounded  by  these  glands  and  thus 
discharge  themselves.  This  is  one  of  the  possible  causes  of  expectorated  cal- 
culi.— Examples  may  be  found  in  the  Clinique  Medicate. — Andral. 

*  Obs.  Pathol.  Anat. — Leip.  1793.        t  Sec  Bull,  de  la  SocitU  de  Medecine. 


20 


154 

BOOK  THIRD. 

DISEASES  OF  THE  LUNGS. 


Previously  to  giving  an  account  of  the  organic  alterations  to 
which  the  lungs  are  liable,  it  will  be  proper  to  take  a  view  of 
the  different  opinions  which  have  been  published  respecting  the 
intimate  structure  of  these  organs.  Malpighi  conceived  that  the 
air  cells  were  formed  by  the  inner  membrane  of  the  bronchi  be- 
ing divided,  previously  to  their  termination,  into  cells  like  those 
of  a  sponge.*  Helvetius  fancied  that  lie  had  ascertained  by 
direct  experiment,  that  the  air  cells  were  formed  by  a  simple 
cellular  tissue,  disposed  without  any  regular  order,  and  derived 
from  the  cellular  envelopes  of  the  various  vessels  by  which  the 
lungs  are  tra versed  .f  Haller  entertained  almost  the  same  opin- 
ion, which  is,  indeed,  that  of  the  greater  number  of  anatomists.^ 
Reisseissen,  on  the  other  hand,  by  means  of  a  great  many  mi- 
croscopical observations  and  mercurial  injections,  has  ascertained 
that  the  bronchi,  at  their  extremities,  are  subdivided  into  a  mul- 
titude of  small  canals,  terminated  by  culs-de-sac  of  a  globular 
form,  grouped  somewhat  in  the  manner  of  the  terminal  branch- 
lets  of  the  cauliflower. §  A  pupil  of  the  Faculty  of  Paris,  in  his 
inaugural  dissertation,  published  in  1823,  has  given  an  opinion 
altogether  new  respecting  the  structure  of  the  lungs.  He  imagines 
that  the  principal  bronchial  trunk  distributed  in  each  lobule,  be- 
fore entering  this,  divides  into  two  branches,  each  of  these  into 
two  more,  and  so  on  successively,  with  a  regular  continuous 
bifurcation ;  by  which  means  a  still  increasing  series  of  canals 
are  formed,  which  cross  each  other  in  every  possible  direction, 
and  each  of  which  is  accompanied  in  its  course  by  a  twig  of  the 
pulmonary  artery  and  veins.  He  imagines  that  these  canals 
terminate,  at  the  exterior  of  each  lobule,  in  the  cellular  mem- 
brane which  surrounds  it,  without  being  reflected  and  without 
anastomosing  with  one  another.  ||  The  process  by  which  he  was 
led  to  this  conclusion,  consists  in  drying  the  lungs  after  they 
have  been  inflated,  and  then  cutting  them  in  slices,  with  a  sharp 

*  Epist  i.  De  Pulmone.     Bolon.  1661. 
t  Mem.  de  l'Acad.  des  Sc.     1718. 
JElemen.  Physiol,  t.  iii.  p.  171,  et  seq. 

§  De  Fabrica  Pulmonum  a  Rev.  Acad.  Scient.  Barolin,  pram,  ornata.     Bero- 
lini,  1822,  in  fol. 

||  Picard,  Dissertation  sur  la  Pneumonic  aigue.     Paris,  1823. 


STRUCTURE    OF    THE    LUNGS. 


155 


bistoury.  He  asserts  that  in  whatever  direction  the  incision  is 
made,  we  can  perceive  canals  which  are  perpendicular,  and  others 
which  are  inclined  to  the  surface  of  the  incision.  I  have  repeated 
this  experiment  without  corning  to  the  same  conclusion.  On  the 
contrary,  beside  the  very  minute  bronchial  tubes  distinguishable 
by  their  elongated  form,  I  have  always  observed  a  great  number 
of  small  vesicles,  or  what  appeared  to  be  such.  Moreover,  the 
process  of  insufflation  and  dessication,  however  carefully  per- 
formed, is  always  attended  with  a  contraction  or  crisping,  which 
diminishes  the  regularity  of  shape  of  the  air  cells  and  bronchial 
tubes,  and  prevents  our  seeing  any  thing  very  distinctly.  Neither 
does  the  process  of  injection  yield  us  results  which  are  entirely 
satisfactory.  It  is  well  known,  that  whether  we  inject  the 
bronchi,  the  veins,  or  the  arteries,  the  matter  of  the  injection 
always  passes,  more  or  less,  into  these  three  orders  of  vessels, 
and  frequently  leaves  only  a  confused  mass.  However,  I  must 
admit  that  the  most  successful  injections  which  I  have  made, 
have  appeared  to  me  to  confirm  the  observations  of  Reisseissen  ; 
and  that  the  character  of  the  pulmonary  structure,  when  ex- 
amined in  a  state  of  hepatization,  haemoptysical  induration,  or 
emphysema,  is  much  more  in  accordance  with  his  ideas  than  with 
those  of  the  others.  It  has  also  appeared  to  me,  that  in  the  pro- 
cess of  insufflation  the  air  penetrated  the  small  blood  vessels,  a 
circumstance  which  may  have  tended  to  mislead  M.  Picard. 

We  may  here  observe,  that  the-  intimate  structure  of  all  the 
animal  organs,  is  nearly  as  little  within  the  reach  of  our  eye- 
sight or  instruments,  as  is  that  of  the  lungs ;  and,  consequently, 
that  we  ought  to  consider  nothing  as  certain,  in  pathological 
anatomy,  beyond  those  well-marked  alterations  of  structure 
which  fall  within  the  cognizance  of  our  senses,  and  which  alter 
the  organization  of  a  part,  in  a  way  evidently  incompatible  with 
the  exercise  of  its  functions.  To  justify  us  in  considering  any 
organic  alteration  as  the  cause  of  disease  or  death,  we  ought, 
moreover,  to  be  certain  that  the  appearances  presented  to  us 
have  not  been  the  result  of  decomposition  after  death,  or  of  con- 
gestions which  take  place  during  the  course  of  diseases,  especially 
in  the  last  agony,  and  which  are  susceptible  of  increase  in  the 
period  immediately  subsequent  to  death.  If  these  principles  are 
disregarded,  and  the  causes  of  severe  diseases  sought  for  in  mere 
microscopical  alterations  of  structure,  it  is  impossible  to  avoid 
running  into  consequences  the  most  absurd :  and,  if  once  culti- 
vated in  this  spirit,  pathological  anatomy,  as  well  as  that  of  the 
body  in  a  sound  state,  will  soon  fall  from  the  rank  which  it  holds 
among  the  physical  sciences,  and  become  a  mere  tissue  of  hypo- 
theses, founded  in  optical  illusions  and  fanciful  speculations, 
without  any  real  benefit  to  medicine. 


156  STRUCTURE    OF    THE    LUNGS. 

But,  whatever  be   the   intimate   structure  of  the  pulmonary 
tissue,  if  we  examine,  in  a  good  light,  the  surface  of  a  sound 
lung,  we  can  ascertain  by  the  naked  eye,  through  the  transparent 
pleura,  that  its  parenchyma  is  formed  by  the  aggregation  of  a 
multitude  of   small  vesicles,  of  an  irregularly  spheroid  or   ovoid 
figure,  full  of  air,  and  separated    from  each  other  by  opaque 
white   partitions.     These  vesicles,  which  on  the  surface  of  the 
lungs  have  the  appearance  of  small  transparent  points,  are  not  of 
an   uniform  size.     The  largest  are  equal  to  the  third  or  fourth 
part  of  a  millet  seed.     They  are  grouped  in  masses  or   lobules, 
divided  from   each  other  by  partitions  of  closely-condensed  cel- 
lular membrane,  very  thin,  yet  thicker  and  more  opaque  than 
the  partitions   between    the    individual    cells.     These  partitions 
traverse  the  pulmonary  substance  in  all  directions,  and  crossing 
each  other  under  various  angles,  form  figures  of  different  shapes, 
such  as  lozenges,  squares,  trapeziums,  or  irregular  triangles.     It 
is  along  the  bounding  lines  of  these  figures,  that  the  black  pul- 
monary matter  is  deposited   in  greatest  abundance,  as   I  shall 
show  more  particularly  when  treating  of  melanosis,  with  which 
this  substance  is  frequently  confounded.     I  shall  only  remark  in 
this  place,  that  it  is  from  this  substance  (which    cannot  be  con- 
sidered as  morbid  since  it  always  is  found  in  adult  lungs)  that 
the  small  black  dots  sometimes  observed   in  the  pearly  sputa  of 
the  dry  catarrh,   are  derived  ;  as  also  the  blackish  or  grey  color 
of  certain  kinds  of  mucous  expectoration,  and  the  greyish  tint 
occasionally  exhibited  by  the  matter  of  pulmonary  abscess,  which 
resembles  a  mixture  of  pus  and  ashes.     This  black  matter  is  not 
found  in  the  lungs  of   young  children.     In  adults  and  elderly 
persons  it  is  more  or  less  abundant ;  while  in  very  old  subjects  it 
perhaps  is  found  in  less  quantity.     In  the  last-named  class  of 
persons  the  lungs  present  some  other  remarkable  characters :  the 
calibre  of  all  their  vessels  seems  diminished  ;    they  become  in 
some  sort  exsanguine  ;  the  partitions  of  the  air  cells  appear  thin- 
ner than  natural,  on  which  account   their  substance,  rendered 
more  rare,  becomes  less  elastic,  and  thus  yielding  to  the  atmos- 
pheric pressure  on  the   opening  of  the  body,  they  are  found  to 
occupy  not  more  than    one-third  of  the  cavity  of   the  pleura. 
They  may  be  said   to  bear  the  same  relation  to  the  lungs  of  an 
adult,  that  muslin  bears  to  a  finer  cloth,  which  is  of  a  texture  at 
once  strong  and  close.     These  characters  are  especially  observa- 
ble in  the  lungs  of  octogenarians  * 

*, -£he  vesicles.  of  the  lungs  undergo  at  different  periods  of  life  remarkable 
modifications.  In  infancy  they  are  very  small  and  very  numerous ;  at  this  peri- 
od the  lungs  possess  the  greatest  possible  density.  During  adult  age,  they 
begin  to  dilate  :  in  old  age  they  become  enlarged  in  a  singular  manner.  It  is- 
in  this  last  stage  of  life  that  we  can  with  most  advantage,  study  the  structure 


STRUCTURE    OP    THE    LUNGS.  157 

The  black  pulmonary  matter  is  not  the  only  cause  which  may 
so  change  the  appearance  of  an  organic  disease  of  the  lungs,  as 
to  render  it  occasionally  a  matter  of  some  difficulty  to  recognize 
it  in  the  dead  body.  The  serous,  sanguinolent,  or  sanguineous 
infiltrations,  found  toward  the  roots  and  posterior  parts  of  the 
lungs,  in  almost  every  dead  body,  are  a  still  more  frequent 
source  of  mistakes.  The  infiltrations  of  blood  vary  much  in  de- 
gree and  in  appearance.  Externally  the  lung,  in  the  a'ffected 
part,  is  of  a  violet  color  more  or  less  deep.  In  some  points  the 
color  is  almost  black,  and  when  these  points  are  exactly  cir- 
cumscribed, they  may  be  mistaken  by  an  inexperienced  observer 
for  gangrenous  eschars ;  as  I  have  actually  seen  happen  in  reports 
made  in  courts  of  justice*.  Internally,  the  pulmonary  substance 
is  gorged  with  a  greater  or  less  quantity  of  blood,  and  is  more 
dense  and  less  crepitous  than  natural.  Frequently  the  contained 
blood  appears  half  coagulated,  and  cannot  be  easily  expelled  by 
pressure  ;  but  it  is  not  nearly  so  concrete  nor  so  intimately  com- 
bined with  the  pulmonary  substance,  as  in  the  infiltration  of 
haemoptysis.  If  the  examination  has  riot  been  made  until  some 
time  after  death,  and  when  the  process  of  decomposition  has 
already  begun,  the  infiltrated  parts  become  so  soft,  as,  when 
pressed  between  the  fingers,  to  resemble  paste,  of  a  brownish  or 
deep  violet  color.  This  last  color  is  particularly  observable 
when  the  infiltration  has  commenced  before  death,  and  is  com- 
bined with  some  degree  of  what  I  term  peripneumony  of  thq, 
dying,  to  be  noticed  hereafter. 

and  arrangement  of  these  vesicles.  The  change,  however,  which  takes  place 
in  the  texture  of  the  lungs  of  aged  persons,  goes  still  further.  A  period  arrives 
when  the  partitions  of  these  vesicles,  after  a  gradual  diminution  in  thickness, 
end  in  a  complete  atrophy,  break  «and  disappear,  like  the  pupillary  membrane 
of  a  seventh-month-fcetus.  We  then  find  in  the  lungs  certain  cavities  filled  with 
air,  caused  by  the  union  of  a  number  of  vesicles  whose  partitions  have  decayed 
and  given  way.  These  cavities  are  generally  traversed  by  a  species  of  irregular 
filaments,  which  are  evidently  the  remains  of  the  decayed  partitions  of  the 
vesicles. 

Under  this  modification  of  their  structure,  the  lungs  of  aged  people  resemble, 
in  organization,  those  of  reptilqs,  and  this  gives  rise  to  a  necessary  change,  in 
the  manner  of  accomplishing  their  functions :  a  less  quantity  of  blood  in  a 
given  time  is  brought  into  contact  with  the  air,  consequently  the  function  of 
sanguification  becomes  less  active.  These  lungs  are  generally  bloodless  and 
psile  :  less  blood  passes  through  them  than  at  an  earlier  period  of  life,  and  it  is 
thus  that  the  structure  of  the  vesicles  is  enabled  to  support  the  alteration  above 
described  without  causing  any  considerable  trouble  in  the  breathing.  If,  on  the 
contrary,  the  partitions  of  the  vesicles  should  decay  faster  than  the  amount  of 
blood  diminishes  which  at  one  circulation  passes  through  the  lungs,  a  dyspnoea 
arises,  slight  at  first,  but  soon  increasing.  This  dyspnoea  attacks  persons  ad- 
vanced in  age,  who  up  to  that  time  exhibited  no  symptoms  of  disease  either  jn 
the  lungs  or  heart:  they  have  no  cough  or  indication  of  catarrh  :  the  action  of 
the  heart  is  no  way  troubled  :  a  difficulty  of  breathing  is  all  they  complain  of. 
If  auscultation  be  employed  in  such  cases,  no  extraordinary  sound  whatever  ia 
heard.  Nothing  is  noticed  except  a  remarkable  feebleness  of  the  respiratory 
murmur. — Andral. 


158  STRUCTURE    OF    THE    LUNGS. 

The  kind  of  infiltration  just  described,  is  that  observed  in  sub- 
jects whose  blood-vessels  and  capillaries  contain  much  blood,  and 
particularly  in  those  who  have  died  of  acute  fever  or  scurvy.  In 
exsanguine  subjects,  on  the  contrary,  and  particularly  in  such  as 
have  died  of  cancer,  the  infiltration  of  the  same  parts  exhibits 
merely  a  simple  red  hue  of  the  pulmonary  substance,  and  does 
not  render  this  at  all  less  crepitous,  or  more  disposed  to  pour 
out  fliiid  when  incised.  In  dropsical  cases,  in  place  of  blood, 
there  is  frequently  a  very  frothy  serum,  more  or  less  tinged  with 
blood.  Sometimes  this  is  nearly  colorless  ;  and  in  cases  of  this 
kind  the  state  of  parts  sometimes  closely  resembles  the  first  stage 
of  peripneumony  or  oedema  of  the  lungs,  and,  indeed,  can  only 
be  distinguished  from  them  by  this  circumstance, — that  the  dis- 
eases mentioned  affect  the  lungs  indifferently  and  without  regard 
to  the  laws  of  hydrostatics ;  whilst  the  mechanical  infiltration 
after  death,  is  always  most  considerable  in  the  lowest  portion  of 
the  lungs. 

Bichat  was  the  first  who  called  the  attention  of  morbid  ana- 
tomists to  this  circumstance :  he  pointed  out  its  analogy  with  the 
dark-colored  marks  observed  on  the  back  and  under  parts  of  the 
limbs  of  almost  all  dead  bodies ;  and  considered  both  as  owing 
to  the  custom  of  placing  them  on  the  back.  His  opinion  was 
founded  on  the  experiment,  which  I  have  myself  several  times 
repeated,  of  placing  the  bodies  on  the  belly  immediately  after 
death. 

It  is  to  be  observed,  however,  that  we  sometimes  see  the  dark 
stains  above  mentioned,  on  the  posterior  parts  of  the  body  one 
or  two  days  before  death,  in  patients  who  are  extremely  debili- 
tated, and  particularly  in  cases  of  severe  fever.  In  like  manner, 
the  sanguineous  or  serous  infiltration,  of  the  posterior  part  of  the 
lungs,  frequently  commences  several  hours  before  death.  From 
unwillingness  to  distress  the  dying,  I  have  not  ascertained  the 
correctness  of  this  statement  in  most  cases  ;  but  I  have  done  so 
in  almost  every  case  where  I  have  made  the  experiment.  A  sub- 
crepitous  and  mucous  rhonchus  over  the  lower  parts  of  the  back 
and  at  the  roots  of  the  lungs,  almost  constantly  accompanies  the 
tracheal  rhonchus  of  the  last  agony.  It  is  in  this  way  that  we 
account  for  the  oppressed  breathing  observable  in  most  dying  per- 
sons, even  in  cases  where  the  organs  of  respiration  have  remained 
without  any  appearance  of  disorder  through  the  whole  course  of 
the  disease.* 

•*  The  author  seems  here  to  overlook  the  gradual  failure  of  the  vital  powers, 
as  specially  affecting  respiration  through  the  diminished  energy  of  the  muscles 
of  respiration  of  the  heart.—  Transl. 


HYPERTROPHY  OF  THE  LUNGS.  159 


CHAPTER  I. 

OF    HYPERTROPHY    OF    THE    LUNGS. 

Hypertrophy  or  superabundant  nutrition,  is  the  most  simple 
morbid  alteration  to  which  our  organs  are  subject.  It  is  indicated 
by  increase  of  the  size  and  sometimes  of  the  consistence  of  the 
organic  texture.  It  is  productive  of  no  inconvenience  unless  it 
happens  to  affect  a  part  whose  increased  energy  of  action  disturbs 
the  equilibrium  of  the  functions  of  the  body.  In  certain  cases  it 
evidently  results  from  the  efforts  of  nature  to  remove  disease  ; 
as  in  the  instance  of  the  lungs,  and  indeed  in  most  double  organs, 
such  as  the  kidneys  and  testicles.  When  any  one  of  these  organs 
is  destroyed,  or  from  any  cause  rendered  unfit  for  the  perform- 
ance of  its  functions,  its  fellow  acquires  a  double  energy,  conse- 
quently an  increase  of  nutrition,  and,  after  a  certain  time,  an 
augmentation  of  volume. 

In  the  case  of  the  lungs,  it  was  observed  by  Morgagni,  that 
in  empyema  with  compression  of  the  lung,  the  viscus  on  the  op- 
posite side  was  occasionally  increased  in  size.  The  circumstance 
is  indeed  much  more  general  than  this  author  imagined ;  as  it, 
in  fact,  occurs  in  every  instance  in  which  one  of  the  lungs  is  ren- 
dered useless  for  a  certain  time, — a  few  months,  for  example.  It 
is  accordingly  met  with  not  only  after  empyema,  but  after 
pneumo-thorax,  hydro-thorax,  and  still  more,  after  contraction 
of  the  chest,  the  consequence  of  severe  pleurisy,  or  pulmonary 
excavations  of  a  large  size.  In  all  these  cases,  the  lung  increases 
in  volume,  and  becomes  at  the  same  time,  firmer,  more  elastic, 
and  more  compact.  In  place  of  collapsing  when  the  chest  is  laid 
open,  it  sometimes  protrudes  from  it,  as  if  the  space  that  con- 
tained it  were  too  small.  In  instances  of  this  sort  it  cannot  be 
doubted  that  the  air  cells  are  enlarged,  and  that  their  parietes 
have  acquired  a  preternatural  thickness  ;  although  it  is  extremely 
difficult  to  prove  this,  even  with  the  aid  of  the  microscope. 

Hypertrophy  of  the  lungs  is  sometimes  formed  in  a  very  short 
space  of  time  :  in  the  case  of  a  man  who  had  pleurisy  and  con- 
sequent contraction  of  the  chest  (to  one-half  its  natural  size) 
from  rupture  of  a  vast  tuberculous  excavation  into  the  pleura, 
and  who  had  the  good  fortune  to  survive  this  complicated 
malady,  I  found  the  hypertrophy  existing  in  the  highest  degree, 
only  six  months  after  the  invasion  of  the  disease.* 

Emphysema  of  the  lungs,  as  we  shall  see  hereafter,  i*  also 

*  This  man  was  killed,  shortly  after  his  cure,  by  a  blow  on  the  head. — Author. 


160  ATROPHY  OF  THE  LUNGS. 

accompanied,  in  most  cases,  with  hypertrophy  of  the   pulmonary 
substance. 

The  same  characters  of  firmness  and  elasticity  in  a  perfectly 
crepitous  lung,  which  I  have  before  mentioned  as  belonging  to 
hypertrophy  of  this  viscus,  are  sometimes  also  observable  imme- 
diately after  the  resolution  of  pneumonia.  But  in  this  case  it  is 
to  be  presumed  that  such  qualities  are  only  temporary,  and  de- 
pend upon  an  interstitial  infiltration  of  serum.* 


CHAPTER  II.  , 

,  OF    ATROPHY    OF    THE    LUNGS. 

The  lungs  belong  to  that  class  of  organs  which  are  unaffected, 
at  least  perceptibly,  by  general  emaciation  of  the  body.  They 
diminish  in  size  only  from  the  effects  of  external  pressure,  or  in 
consequence  of  the  growth  of  accidental  productions  within  their 
substance,  which  may  be  considered  as  exerting  a  pressure,  from 
within  outwards.  In  the  case  of  effusions  into  the  pleura,  par- 
ticularly the  purulent,  the  lungs  are  compressed  against  the  me- 
diastinum, and  are  sometimes  reduced  to  a  layer  not  half  so  thick 
as  the  hand.  After  the  removal  of  effusions  of  less  extent,  they 
continue  to  adhere  to  the  side,  and  hardly  ever  regain  their 
original  volume,  even  after  the  restoration  of  very  perfect  respi- 
ration. The  same  actual  wasting  of  the  pulmonary  tissue,  must 
be  admitted  m  those  instances  in  which  a  great  number  of  tu- 
bercles or  other  accidental  productions  are  developed  in  the 
lungs,  without  any  condensation  of  the  intermediate  sound  sub- 
stance;! and  indeed  we  frequently  observe  that  a  lung  which 
contains  a  vast  number  of  tubercles  is  actually  less  than  that  of 
the  opposite  side,  which  contains  a  much  smaller  number.  This 
remark  was  made  by  Bayle  ;  but  he  went  a  little  too  far  in  draw- 
ing the  conclusion  from  it  that  the  chest  of  every  phthisical  sub- 
ject is  necessarily  contracted. 

*  For  ampler  details  respecting  hypertrophy  and  atrophy  of  the  lungs,  the 
reader  is  referred  to  Andral's  Precis  d'Anatomie  Pathoiogique,  t.  ii.  p.  514,  et 
seq. ;  or  to  the  translation  of  that  excellent  work  by  Townsendand  West:  they 
are  omitted  here,  as  having  no  direct  bearing  on  practice. —  Transl. 

t  In  a  case  where  the  principal  air-tube  of  a  lung  had  been  strongly  con- 
stricted and  almost  obliterated  by  a  tumor  around  it,  I  discovered  a  remarkable 
diminution  in  the  size  of  the  lung  to  which  the  bronchial  tube  transmitted  air. 
The  srirface  of  the  chest  corresponding'to  the  atrophied  lung  had  undergone  a 
depression  very  perceptible  to  the  eye,  as  it  happens  after  pleurisy.— Andral. 


EMPHYSEMA    OF    THE    LUNGS. 


CHAPTER  III. 


OF    EMPHYSEMA    OF    THE    LUNGS. 


161 


Theiie  are  two  kinds  of  emphysema  of  the  lungs,  the  vesicular 
or  pulmonary  properly  so  called,  and  the  interlobular. 

Sect.  I  Of  vesicular  Emphysema. 

This,  next  to  hypertrophy,  is  the  most  simple  of  all  the  or- 
ganic lesions  of  the  lungs,  since  it  consists  simply  in  the  dilata- 
tion of  the  air  cells.  On  this  very  account  it  remained  long 
unknown,  and  has  not  hitherto  been  correctly  described  by  any 
author.  I  for  a  long  time  thought  it  very  uncommon,  because 
I  had  observed  only  a  few  cases  of  it ;  but  since  I  have  made 
use  of  the  stethoscope,  I  have  verified  its  existence  as  well  on  the 
living  as  the  dead  subject,  and  am  led  to  consider  it  as  by  no 
means  infrequent.  I  consider  many  cases  of  asthma,  usually 
deemed  nervous,  as  depending  on  this  cause.  The  chief  reason 
of  this  affection  having  been  so  completely  overlooked  is,  that  it 
is  in  some  sort  merely  the  exaggeration  of  the  natural  condition 
of  the  viscus. 

Anatomical  characters. — In  pulmonary  emphysema,  the  size 
of  the  vesicles  is  much  increased,  and  is  less  uniform.  The 
greater  number  equal  or  exceed  the  size  of  a  millet-seed,  while 
some  attain  the  magnitude  of  hemp-seed,  cherry-stones,  or  even 
French  beans  (haricot.)  These  latter  are  probably  produced  by 
the  re-union  of  several  of  the  air  cells  through  rupture  of  the 
intermediate  partitions ;  sometimes,  however,  they  appear  to 
arise  from  the  simple  enlargement  of  a  single  vesicle.  The 
largest  of  these  dilated  cells  are  often  in  no  respect  prominent  on 
the  surface  of  the  lung  ;  sometimes  they  form  a  slight  projection. 
In  the  latter  case  the  structure  of  the  lung  acquires  a  striking 
resemblance  to  the  vesicular  lungs  of  the  Linnaean  order  of  Rep- 
tilia.  Sometimes,  though  more  rarely,  we  observe  on  the  surface 
of  the  lung  single  vesicles,  distended  to  the  size  of  a  cherry- 
stone or  larger,  quite  prominent,  exactly  globular,  and  apparently 
pcdiculated.  I  say  apparently  pediculated,  because  on  cutting 
into  them  we  find  that  there  is  no  real  pedicle,  but  merely  a  con- 
striction at  the  point  where  the  cell  begins  to  rise  beyond  the 
surface  of  the  lung.  The  cavity  of  these  dilated  cells  descends 
some  little  way  into  the  substance  of  the  viscus,  and  there  its 
walls  do  not  collapse,  when  cut,  as  in  the  projecting  portion.  At 
21 


162  EMPHYSEMA  OF  THE  LUNGS. 

the  bottom  of  this  inferior  portion  of  the  cavity,  we  find  small 
openings  by  which  the  dilated  cell  communicates  with  the  ad- 
joining ones,  and  with  the  bronchi.  That  these  projecting 
vesicles  are  produced  by  the  dilatation  of  air  cells,  and  are  not 
owing  to  the  extravasation  of  air  under  the  pleura,  is  proved,  as 
well  by  the  prolongation,  just  mentioned,  of  their  cavity,  into  the 
pulmonary  substance,  as  by  the  circumstance  that  we  cannot 
force  the  contained  air,  by  pressure  of  the  finger,  to  leave  its 
place  and  to  pass  under  the  contiguous  pleura, — as  would  be  the 
case  if  it  were  extravasated.  • 

As  long  as  the  parts  continue  in  the  state  above  described,  the 
disease  consists  merely  in  an  excessive,  permanent,  and  unnatural 
distention  of  the  air  cells,  the  air  being  still  contained  in  its 
proper  cavities ;  but  when  the  distention  becomes  still  more 
considerable,  or  takes  place  with  greater  rapidity,  the  air  cells 
are  ruptured  in  certain  points,  and  the  surrounding  cellular 
substance  of  the  lung  becomes  distended  by  extravasated  air, 
exactly  in  the  same  manner  as  in  emphysema  of  the  subcutaneous 
adipose  membrane.  Tn  this  case  we  find  on  the  surface  of  the 
lung  vesicles  of  an  irregular  form,  which  can  be  made  to  change 
their  place  by  pressure  with  the  finger.  They  vary  in  size  from 
that  of  a  hemp-seed  to  that  of  a  walnut,  or  even  an  egg.  Like 
the  simply  dilated  cells,  these  vesicles  contain  nothing  but  air, 
which  makes  its  escape  on  their  being  punctured,  with  a  pin. 
Sometimes  the  air,  though  truly  extravasated  under  the  pleura, 
cannot  be  displaced  by  pressure  in  the  manner  just  mentioned. 
This  happens  when  the  extravasation  is  situated  at  the  point  of 
re-union  of  the  partitions  which  divide  the  different  groups  of 
air  cells,  as  above  mentioned.  In  this  case  the  projection  has 
usually  a  triangular  shape  and  is  not  very  considerable. 

I  have  never  found  this  extravasated  air  penetrate,  to  any 
considerable  extent,  into  the  substance  of  these  interlobular  par- 
titions, nor  into  the  cellular  substance  which  surrounds  the  larger 
blood  vessels  and  bronchial  trunks ;  but  1  have  seen  the  pul- 
monary substance  in  the  interior  of  the  lung  lacerated  by  over- 
distention  of  the  air  cells.  In  these  cases,  over  the  site  of  the 
laceration  we  observe  an  irregular  projection,  on  which  the  di- 
lated cells  are  as  distinct  as  elsewhere.  Upon  cutting  into  this, 
at  a  greater  or  less  depth,  we  find  the  laceration  of  a  propor- 
tionate size  to  the  external  projection.  This  is  found  to  contain 
air,  and  sometimes  also  a  small  quantity  of  blood,  either  coagu- 
lated or  loose  ;  and  the  surrounding  air  cells,  which  form  the 
immediate  walls  of  the  excavation  produced  by  the  rupture,  are 
observed  to  be  loose,  flabby  and  without  their  natural  globular 
figure. 

The  bronchial  tubes,  especially  those  of  a  small  calibre,  are 


EMPHYSEMA    OF    THE    LUNGS.  163 

sometimes  very  evidently  dilated  in  those  portions  of  the  lung 
where  the  emphysema  exists.  This  fact  is  easily  proved  by 
comparing  the  diseased  and  sound  portions  of  the  lungs.  It  was 
to  be  expected ;  and,  indeed,  it  is  singular  that  the  circumstance 
is  not  more  common,  since  the  cause  which  dilates  the  air  cells 
must  act  equally  on  the  bronchi ;  this  dilatation  is,  nevertheless, 
very  rare. 

To  enable  us  to  have  a  correct  notion  of  this  disease,  we  must 
inflate  the  affected  lungs  and  immediately  dry  them.  If  they 
are  then  cut  into  slices  with  a  fine  instrument,  we  perceive  at 
once  that  the  air  cells  are  almost  always  more  dilated  than  they 
appear  externally  ;  insomuch  that  those  which  form  a  projec- 
tion on  the  surface,  of  the  size  of  a  hemp-seed,  are  found  ca- 
pable of  containing  a  cherry-stone.  We  observe,  moreover,  that 
some  of  the  cells  are  simply  dilated,  while  others  are  ruptured, 
the  intervening  partitions  of  several  being  destroyed  more  or  less 
completely. 

When  we  blow  into  an  emphysematous  lung,  the  dilated  and 
projecting  cells  seem  to  become  flatter  the  more  they  are  dis- 
tended, and  fall  down  to  the  general  level  of  the  surface.  This 
is  owing  to  the  greater  relative  extensibility  and  elasticity  of  the 
healthy  cells,  which  in  the  first  instance  rise  to  the  level  of  the 
dilated  cells,  and  then  fall  below  them,  to  their  natural  level. 
The  continued  projection  of  the  dilated  cells  may  be  partly  owing, 
also,  to  the  difficulty  with  which  the  air  escapes  from  them,  mofe 
especially  when  the  exciting  cause  of  the  emphysema  is  the  dry 
catarrh. 

Emphysema  may  affect  both  lungs  at  the  same  time,  one  only, 
or  a  part  of  one  or  of  both.  In  the  latter  case, — and  indeed  in 
any  case,  as  long  as  there  do  not  exist  vesicles  of  considerable 
size  on  the  surface  of  the  lungs — it  is  easy  to  overlook  the  dis- 
ease in  the  dead  subject,  and,  as  I  have  already  said,  I  am  con- 
vinced that  this  has  often  been  done  by  the  best  practical  ana- 
tomists as  well  as  by  myself.  I  am  now  well  assured,  that  if  we 
carefully  examine  the  lungs  of  the  subjects  who  have  long  suffered 
from  the  dispncea,  from  whatever  cause,  we  shall  almost  always 
find  more  or  fewer  of  the  air  cells  dilated.  In  lungs  studded  with 
tubercles,  which  presented  no  other  sigh  of  emphysema,  I  have 
sometimes  found  two  or  three  of  the  cells  dilated  to  the  size  of  a 
hemp-seed. 

When  the  disease  exists  in  a  high  degree,  and  occupies  the 
whole  of  one  or  both  lungs,  we  cannot  help  being  struck  with 
the  appearance  of  the  parts.  The  lungs  seem  as  if  confined  in 
their  natural  cavity,  and,  when  exposed,  instead  of  collapsing 
as  usual,  they  rise  in  some  degree,  and  project  beyond  the  bor- 
ders of  the  thorax.     If  we  examine  them  in  this  state,  they  feel 


164  EMPHYSEMA    OF    THE    LUNGS. 

firmer  than  natural,  and  it  is  more  difficult  to  flatten  or  compress 
them  than  in  ordinary  cases.  The  crepitation  they  afford  on 
pressure  or  on  being  cut  into,  is  less,  and  of  a  kind  somewhat 
different ;  it  is  more  like  the  sound  produced  by  the  slow  escape 
of  air  from  a  pair  of  bellows ;  and  the  air  makes  its  escape  from 
the  cells  much  slower  than  in  a  healthy  state  of  the  organ. 
When  we  detach  the  lung,  the  crepitation  is  found  to  be  still 
less  perceptible,  and  the  sensation  conveyed  by  pressing  the  parts 
is  very  like  that  produced  by  handling  a  pillow  of  down.  This 
seems  to  indicate  either  a  more  difficult  communication  between 
the  air  contained  in  the  air  cells  and  that  in  the  bronchi,  or  else 
a  diminished  elasticity  of  the  air  cells  themselves.  Perhaps  both 
these  causes  conspire  to  produce  the  effect  in  question.  The 
first  clearly  exists  in  a  great  number  of  cases ;  since  we  know 
that  the  dry  catarrh,  and  the  obstruction  of  the  lesser  bronchi, 
an  attendant  on  the  dry  catarrh,  arc  the  most  common  causes  of 
emphysema.  The  second  cause  indicated  is  equally  probable, 
inasmuch  as  the  thickening  of  a  membrane  is  a  very  frequent 
result  of  its  habitual  distention,  and  in  the  present  case,  it  ap- 
pears that  the  state  of  emphysema  is  productive  of  a  certain  de- 
gree of  hypertrophy.  On  placing  an  emphysematous  lung  in  a 
vessel  of  water,  it  sinks  much  less  than  a  healthy  lung  ;  some- 
times it  floats  on  the  surface  with  scarcely  any  obvious  immer- 
sion. The  pulmonary  tissue  is  dryer  in  a  lung  affected  with 
emphysema  than  in  a  healthy  one  ;  and  it  is  unusual  to  find, 
even  towards  the  roots  of  the  lungs,  any  trace  of  the  common 
serous  or  sanguineous  infiltrations  commonly  found  after  death. 
The  contrary,  however,  sometimes  happens,  as  will  be  seen  in 
the  cases  about  to  be  detailed.  A  history  of  what  appears  an- 
other instance  of  this  complication  is  recorded  by  M.  Taranget.* 
In  cases  of  this  kind,  as  in  most  others  in  which  considerable  in- 
filtrations of  the  pulmonary  substance  are  found  after  death,  it  is 
probable  that  the  infiltration  took  place  only  a  few  moments 
before  the  cessation  of  life*  Be  this  as  it  may,  it  is  certain  that 
this  mechanical  engorgement,  as  well  as  cedema  properly  so 
called,  and  also  peripneumony,  render  it  sometimes  a  matter  of 
difficulty  to  recognize  emphysema,  when  not  very  extensive,  in 
the  dead  body.  When  a  single  lung  is  affected,  it  becomes 
much  more  voluminous  than  the  other — so  much  so,  indeed,  as 
sometimes  to  pass  aside  the  heart  and  mediastinum,  and  to  cause 
an  evident  enlargement  of  the  bony  walls  of  that  side  of  the 
chest. 

From  these  observations  it  results,  that  pulmonary  emphysema 
consists  essentially  in  the  dilatation  of  the  air  cells,  and  that  the 

*  Recueil.  Period,  de  la  Soc.  de  Med.  de  Paris,  torn.  xi.  p.  375.    . 


EMPHYSEMA  OF  THE  LUNGS.  165 

extravasation  of  the  air  on  the  surface  of  the  lungs,  constituting 
the  larger  and  more  prominent  vesicles,  is  a  posterior  affection, 
and  not  necessarily  connected  with  the  disease  in  question.*  The 
latter  species  of  lesion  is,  moreover,  of  slight  consequence  com- 
pared with  the  dilatation  of  the  cells,  as  we  can  hope  for  its  re- 
moval by  absorption,  as  in  other  similar  cases  ;  whilst  we  cannot 
well  see  in  what  manner  either  nature  or  art  can  remedy  the 
other  morbid  derangement.  At  the  same  time,  I  do  not  think 
we  are  justified  in  considering  this  affection  as  altogether  in- 
curable. In  several  instances  I  have  fancied  that  I  discovered 
the  traces  of  cicatrization  of  ruptures  of  the  pulmonary  tissue, 
of  the  kind  above  described.  In  the  case  of  subjects  affected 
with  asthma,  I  have  several  times,  during  the  fits,  detected  a 
crepitous  rhonchus  with  large  bubbles,  in  particular  points,  which 
rhonchus  entirely  disappeared  afterwards  ;  and  it  is  quite  intelli- 
gible that  if  we  can  diminish  the  intensity  of  the  cause  which 
keeps  up  the  habitual  distention  of  the  cells,  we  may  in  the  end 
hope  that  these  will  be  actually  lessened  in  volume. 

The  emphysema  of  the  lungs,  of  which  I  have  just  given  the 
description,  appears  to  me,  as  I  have  already  observed,  to  have 
been  hitherto  unknown.  No  general  description  of  it  certainly 
exists  ;  although  facts,  that  evidently  can  be  only  referred  to  it, 
are  to  be  found  in  several  authors.  Bonetusf  and  MorgagniJ 
give  several  examples  of  the  lungs  being  found  very  voluminous 
and  distended  with  air.  Van  Swieten<§>  and  Storck||  have  some 
cases  wherein  vesicles  of  air  were  found  under  the  pleura :  and 
FloyerU  noticed  the  same  thing  in  a  broken-winded  mare.  The 
author  of  the  article  Emphystme  in  the  Diet,  des  Sciences  Med. 
relates  a  case  precisely  similar  to  these  last  mentioned,  which  had 
been  communicated  to  him  by  M.  Majendie  ;  but  none  of  these 
various  authors  appear    to  have  been  acquainted  with  the  real 

*  This  proposition  is,  however,  now  much  disputed.  Andral  regards  the  phe- 
nomena described  as  vesicular  emphysema  by  Laennec,  as  merely  hypertrophy 
or  atrophy  of  the  lungs,  and  recognises  no  other  species  of  pulmonary  emphy- 
sema, but  that  which  our  author  terms  interlobular.  (Precis  d'  J3nat.  Path.  t.  ii. 
|>.  530.J  This  is  also  the  opinion  of  M.  Piedagnel,  (Kcchercltes  sur  I'cmphysime 
du  poumon,  Vans,  1829,)  who,  moreover,  contends  that  this  species  of  emphy- 
sema exists  in  every  case  in  which  the  lungs  are  found  crepitant,  or  yielding  the 
crepitous  sound  on  compression.  It  is,  however,  evident  from  M.  Piedagnel's 
own  observations  that  there  is,  in  reality,  in  the  greater  number  of  cases,  a  dila- 
tation of  the  air  cells  antecedent  to  the  extravasation  of  the  air  in  the  interlob- 
ular tissue  of  the  lungs :  I  conceive,  therefore,  that  his  opinion  does  not  differ  • 
materially  from  that  of  Laennec  which  lie  combats  ;  the  latter  having  never  pre- 
tended that  the  emphysema  consists  exclusively  in  dilatation  of  the  air  cells. — 
(M.  L.) 

I  Sepulchret.  lib.  ii.  sect.  1. 

t  Epist.  iv.  sect.  24.  et  Epist.  xviii.  sect.  14. 

§  Comment,  in  Boerh.  aph.  1220. 

||  Ann.  Med.  Prim.  p.  114.  Ann.  Med.  Secund.  p.  239. 

Tl  Treatise  on  Asthma. 


166  EMPHYSEMA    OF    THE    LUNGS. 

character  of  the  affection,  viz. — dilatation  of  the  bronchial  cells. 
All  of  them  seem  to  have  thought,  with  the  last-mentioned  wri- 
ter, who  expresses  his  opinion  in  a  positive  manner,  that  the  de- 
rangement in  question  consisted  in  the  infiltration  of  the  cellular 
substance  of  the  lungs  with  air.  Ruysch  and  Valsalva  are  the 
only  authors,  as  far  as  I  know,  who  have  observed,  in  individual 
cases  the  dilatation  of  the  cells.  The  case  noticed  by  the  latter 
is  an  example  of  partial  emphysema  of  the  lungs  complicated 
with  empyema.  It  has  been  noticed  under  its  latter  character 
by  Morgagni,  who  does  not  appear  to  have  understood  the 
nature  of  the  formeV  change  of  structure.  This,  however,  he 
has  described  in  a  manner  to  leave  no  doubt  of  its  true  nature. 

"  Sinistri  pulmonis  lobus  superior qua  claviculum  specta- 

bat,  vesiculas  ex  quibus  constat  mirum  in  modum  auctas  habe- 
bat ;  ut  nonnullae  avellanae  magnitudinem  aequarent ;  casterte 
multo  minores  erant.  Qusedam  globuli  figura,  reliquac  oblonga 
et  ovali :  omnes  plenae  erant  aeris  ....  una  insuper  minima  quas- 
dam  foraminula  per  interiorem  faciem  hiantia  ostendit."* 

The  case  noticed  by  Ruysch  is  also  one  of  partial  emphysema 
•of  the  lungs :  "  In  aliqua  autem  pulmonis  parte  inveni  vesicula- 
rum  pellucidarum  acervum,  ab  aere  expansarum  et  ita  obstruc- 
tarum  ut  levi  compressione  eas  ab  aere  evacuare  haud  potucrim. 
Impulsum  per  asperam  arteriam  flatum  nullum  commercium 
cum  hisce  expansis  vesiculis  amplius  habere  propter  earum  ob- 
structionem  expertus  sum.  Post  aere  per  asperam  arteriam 
vehementer  adacto  disrumpebantur  nonnullae  ex  his  vesiculis. "f 
This  author  has,  perhaps,  a  second  case  of  the  same  kind,  (obs. 
20,)  but  it  is  too  imperfectly  described  to  justify  any  deductions 
from  it. 

Dr.  Baillie,  author  of  the  Morbid  Anatomy,  has  correctly  ob- 
served the  three  principal  circumstances  which  constitute  emphy- 
sema of  the  lungs,  namely — the  great  size  of  these  organs, — the 
dilatation  of  the  cells, — ^and  the  vesicles  formed  by  the  extrava- 
sation of  air  under  the  pleura ;  but  he  does  not  appear  to  have 
been  acquainted  with  the  mutual  dependence  of  these  three  states, 
and  describes  them  as  three  different  affections,  as  is  evident  from 
the  following  passages  which  contain  all  that  he  says  on  this  sub- 
ject. 

"  Lungs  distended  with  air.  In  opening  into  the  chest,  it  is 
not  unusual  to  find  that  the  lungs  do  not  collapse,  but  that  they 
fill  up  the  cavity  completely  on  each  side  of  the  heart.  When 
examined,  their  cells  appear  full  of  air,  so  that  a  prodigious 
number  of  small  white  vesicles  are  seen  upon  the  surface  of  the 
lungs  immediately  under  the  pleura.    The  branches  of  the  trachea 


*  De  Sed.  et  Caus.  Morb.,  lib.  ii.  epist.  xxii.  12  et  13. 
t  Ruysch,  Obs.  Anat.  Centaur,  obs.  xix. 


EMPHYSEMA    OF    THE    LUlfGS.  167 

are  often  at  the  same  time  a  good  deal  filled  with  the  mucous 
fluid.  This  fluid  had  probably  prevented  the  ready  egress  of  the 
air,  so  that  it  had  gradually  distended  the  air  cells  of  the  lungs, 
and  had  prevented  the  lungs  from  collapsing." 

"  Air  cells  of  the  lungs  enlarged.  The  lungs  are  sometimes, 
although  I  believe  very  rarely,  formed  into  pretty  large  cells,  so 
as  to  resemble  somewhat  the  iungs  of  an  amphibious  animal.  Of 
this  I  have  now  seen  three  instances.  The  enlargement  of  the 
cells  cannot  well  be  supposed  to  arise  from  any  other  cause,  than 
the  air  being  not  allowed  the  common  free  egress  from  the  lungs, 
and  therefore  accumulating  in  them.  It  is  not  improbable  also 
that  this  accumulation  may  sometimes  break  down  two  or  three 
contiguous  cells  into  one,  and  thereby  form  a  cell  of  a  very  large 
size."    . 

"  Air  vesicles  attached  to  the  edge  of  the  lungs.  Vesicles 
containing  air  have  occasionally  been  seen  attached  to  the  edge  of 
the  lungs.  They  do  not  communicate,  however,  with  the  struc- 
ture of  this  organ,  but  are  complete  in  themselves.  Upon  the 
first  view,  it  might  be  thought  probable  that  they  were  merely 
some  of  the  air  cells  enlarged ;  but  as  they  do  not  communicate 
with  any  of  the  air  cells,  this  opinion  is  not  well  founded.  It  is 
most  likely  that  they  are  a  morbid  structure,  formed  in  the  same 
manner  as  the  air  vesicles  attached  to  the  intestines  and  mysen- 
tery  of  some  quadrupeds,  and  that  the  very  minute  blood  vessels 
which  ramify  upon  the  vesicles,  have  the  power  of  secreting  the 
air."* 

He  afterwards  adds,  (p.  86,)  "  When  the  cells  of  the  lungs  are 
much  enlarged  in  their  size,  persons  have  been  remarked  to  have 
been  long  subject  to  difficulty  of  breathing,  more  especially  on 
motion  of  the  body :  but  I  believe  no  symptom  is  at  present 
known,  by  which  this  disease  may  be  ascertained  from  some 
others  incident  to  the  chest." 

Occasional  causes.  Pulmonary  emphysema  supervenes  almost 
always  to  an  extensive  and  severe  dry  catarrh  ;  and  nearly  all  the 
subjects  of  asthma  from  the  last-named  disease,  on  examination 
after  death,  exhibit  a  greater  or  less  dilatation  of  some  of  the 
bronchial  cells.  These  facts  lead  us  to  a  simple  explanation  of 
the  mechanism  of  dilatation  of  the  air  cells.  It  has  been  already 
shown  that,  in  the  dry  catarrh,  the  smaller  bronchial  tubes  are 
frequently  completely  obstructed,  either  by  the  pearly  sputa  or 
by  the  swelling  of  their  inner  membrane.  Now  since  the  muscles 
of  inspiration  are  numerous  and  powerful,  while  expiration,  on 
the  other  hand,  is  produced  merely  by  the  elasticity  of  the  parts 
and  by  the  feeble  contraction  of  the  intercostal  muscles,  it  must 

*  Morbid  Anat.  5th  cd.  p.  78.  et  seq. 


168  EMPHYSEMA    OF    THE    LUNGS. 

frequently  happen  that  the  air,  which  during  inspiration  had 
overcome  the  resistance  opposed  to  its  entrance  by  the  tumid 
state  of  the  bronchial  membrane  and  the  sputa,  is  unable  to  force 
the  same  obstacles  during  expiration,  and  remains  therefore  im- 
prisoned in  the  cells,  by  a  mechanism  somewhat  similar  to  the 
valve  of  an  air  gun.  The  succeeding  inspirations,  or  at  least 
such  of  them  as  are  energetic,  introduces  a  fresh  supply  of  air  into 
the  same  cells,  and  thereby  necessarily  occasion  their  dilatation ; 
and  provided  the  obstruction  is  of  some  continuance,  the  dilated 
condition  of  the  cells  will  be  rendered  permanent.  The  increased 
temperature  and  consequent  dilatation  of  the  air,  after  it  is  re- 
ceived into  the  lungs,  will  have  some  effect  also  in  distending  the 
containing  cells.*  It  follows  from  this  view  of  the  matter,  that 
the  dry  catarrh  tends  as  naturally  to  the  production  of  .emphy- 
sema of  the  lungs,  as  the  chronic  mucous  catarrh  leads  to  dilata- 
tion of  the  bronchi.f 

*  I  gave  this  explanation  of  the  phenomena  to  the  Royal  College  of  France 
in  the  scholastic  year  of  1823-24  :  on  which  occasion  one  of  my  pupils,  M.  Le- 
gallois,  suggested  that  part  of  the  phenomena  of  expiration  might  be  explained 
by  the  necessary  increase  of  volume  (in  the  lungs)  of  the  inspired  air. — Author. 

t  Allowing  that  the  dilatation  of  the  air  vesicles  may  arise  from  the  disten- 
tion of  their  walls  when  any  obstruction  of  the  egress  of  the  air  causes  it  to 
accumulate  in  these  cavities — yet  we  cannot  admit  every  case  of  emphysema  of 
the  lungs  to  be  occasioned  in  this  manner.  It  may  be  presumed  that  every 
violent  effort  may  have  an  influence  in  bringing  on  a  distention  and  rupture  of 
the  vesicles,  but  neither  this  cause  nor  the  other  will  explain  the  production  of 
every  case  of  emphysema  of  the  lungs.  In  fact,  among  those  persons  attacked 
in  this  way,  a  great  number  have  neither  exerted  violent  efforts  of  any  kind, 
nor  been  affected  with  long  and  severe  pulmonary  catarrh  at  any  period, when 
the  existence  of  emphysema  of  the  lungs  has  been  ascertained.  The  researches 
of  M.  Louis  and  myself  have  shown  that  in  many  subjects  who  suffered  from 
this  affection,  the  symptoms  had  existed  from  infancy,  and  that  often  a  habitual 
dyspnaja,  attended  by  no  other  accident,  had  for  a  long  time  preceded  the 
appearance  of  the  cough.  A  different  explanation  from  thai  offered  by  LaenneC 
must  therefore  be  sought  for  the  production  of  at  least  many  cases  of  pulmonary 
emphysema.  Now  if  we  are  guided  by  analogy,  and  enquire  what  are  the  diffe- 
rent morbid  states  exhibited  by  every  hollow  organ  which  undergoes  an  enlarge- 
ment, we  shall  find  the  following  points  established  : — ; 

1.  Cases  occur  where  a  mechanical  obstacle  opposes  the  free  egress  of  the  fluid 
contained  in  the  cavity;  the  cavity  then  enlarges,  while  its  walls  become  thin- 
ner or  thicker  or  remain  the  same. 

2.  Other  cases  occur  where  no  mechanical  obstacle  exists  that  we  can  ascer- 
tain, yet  the  organ  enlarges  spontaneously,  and  its  walls  sometimes  diminish, 
sometimes  increase  in  thickness. 

The  same  changes  of  nutrition  which  alter  the  shape  and  size  of  all  the 
hollow  organs,  may  take  place  in  the  vesicles  of  the  lungs,  each  of  which  may- 
be considered  a  hollow  organ,  destined  to  receive  the  air  which  is  to  vivify  the 
blood.  It  is  easy  to  understand  therefore,  how  emphysema  of  the  lungs  "may 
arise  from  different  sorts  of  change's,  which  result  in  causing  a  simple  distention 
of  the  vesicles,  or  an  obliteration  of  their  walls.  We  see  how  this  takes  place 
with  or  without  a  previous  obstruction  to  the  passage  of  the  air  from  the  vesicles. 
There  is,  then,  no  difficulty  in  admitting  that  in  certain  cases  flic  walls  of  the 
distended  vesicles  may  ut  the  same  time  have  undergone  a  degree  ofthii 
according  to  the  opinion  of  M.  Louis,  while  in  other  cases,  the  same  walls  may  be 
diminished  in  thickness,  as  L  have  proved  in  my  work  on  pathological  anatomy 
It  may  be  remarked  here,  that  these  are  not  more  suppositions,  for  by  drying  an 


EMPHYSEMA  OF  THE  LUNGS.  169 

I  have,  however,  some  reasons  for  believing  that,  in  certain 
cases,  the  dilatation  of  the  cells  is  the  primary  affection,  and  the 
catarrh  consecutive.  In  the  case  of  persons  suffocated  by  the 
gases  of  cess-pools,  I  have  remarked  the  lungs  to  be  very  large, 
and  to  remain  dilated  when  the  chest  was  laid  open,  although 
perfectly  crepitous.  Is  this  owing  to  a  general  dilatation  of  the 
air  cells  ?* 

Certain  other  occasional  causes  may  excite  this  disease,  such 
as  the  long  retention  of  the  breath  in  the  case  of  players  on  wind 
instruments.  The  same  remark  applies  to  violent  efforts  of  any 
kind  which  cause  the  long-continued  retention  of  the  breath ; 
but  these,  as  we  shall  see  hereafter,  give  occasion  still  more  fre- 
quently, to  the  interlobular  emphysema. 

Among  the  rarer  causes  of  the  same  disease  may  be  reckoned 
all  those  which  strongly  compress  the  large  bronchial  trunks,  such 
as  tumors  in  the  bronchial  glands  or  mediastinum,  aneurisms  of 
the  aorta,  polypi  of  the  bronchi,  &c. ;  and  under  the  same  head 
may  be  classed  large  tumors  developed  in  the  lungs  themselves, 
such  as  cysts  or  tubercles.  It  is  by  no  means  unusual,  in  lungs 
filled  with  tubercles  of  a  pretty  large  size,  to  find  some  of  the 
air  cells  dilated  in  different  points.  We  shall  find  hereafter  that 
a  spasmodic  stricture  of  the  bronchi  is  a  frequent  attendant  on 
dry  catarrh ;  and  this  must  contribute  to  the  production  of  em- 
physema. 

Signs  and  symptoms.  Both  the  local  and  general  symptoms 
of  pulmonary  emphysema  are  rather  equivocal.  Dyspnoea  being 
its  principal  feature,  it  is  usually  confounded  under  the  name  of 
asthma.-f     The   difficulty  of  breathing  is  constant,  but  is  aggra- 

cmphysematous  lung,  and  then  examining  the  large  cells  which  have  been  pro- 
duced in  its  tissue  by  the  emphysema,  it  will  be  easily  discovered  that  the  walls 
of  some  of  them  are  thicker  than  natural,  whilst  the  walls  of  other  cells  show, 
on  the  contrary,  a  remarkable  diminution  in  their  thickness.  In  this  last  case, 
the  gradual  destruction  may  be  traced  by  the  eye ;  here  and  there  they  are  seen 
reduced  to  simple  filaments,  causing  a  communication  between  different 
cells,  and  forming  them  into  a  single  cavity.  These  are  changes  analogous  to 
those  which  regularly  take  place  in  the  lungs  of  aged  persons,  being  a  prema- 
ture atrophy,  anatomically  similar  to  that  naturally  produced  in  these  organs  by 
the  simple  process  of  age. — JJndral. 

*  If  the  opinion  noticed  in  the  preceding  note  be  founded  in  truth,  and  1 
think  the  explanation  must  be  admitted  to  a  certain  extent,  it  will  follow  that 
asphj  via  from  carbonic  acid  gas  ought  more  especially  to  give  rise  to  this  dilata- 
tion of  th>'  cells,  since  it  will  be  expired  with  more  difficulty,  on  account  of  its 
greater  specific  gravity. — Author. 

t  The  dyspnoea  which  depends  upon  emphysema  of  the  lungs,  displays  itself 
in  many  instances,  in  early  life,  and  advances  slowly  or  even  remains  stationary 
during  many  years.  Sometimes  it  never  becomes  serious  till  the  individual 
takes  a  cold;  at  this  time  the  first  attack  of  asthma  may  come  on.  On  the 
disappearance  of  the  cold,  the  breathing  becomes  as  free  as  before.  A  second 
cold  will  cause  another  attack  of  asthma,  and  the  dyspnma  advances  little  and 
little  with  fits  of  suffocation  at  intervals.     It  is  rare  to  find  the  breathing  per- 

22 


170  EMPHYSEMA    OF    THE    LUNGS. 

vated  by  paroxysms,  which  are  irregular  both  in  the  period  of 
their  return  and  their  duration  ;  it  is  likewise  increased  by  all 
the  causes  which  usually  increase  dyspnoea,  from  whatever  source 
arising ;  such  as  the  action  of  digestion,  flatulence  in  the  stomach 
or  bowels,  anxiety,  living  in  elevated  situations,  strong  exercise, 
running,  or  ascending  a  height,  and,  above  all,  the  supervention 
of  an  acute  catarrh.  There  is  no  fever,  and  the  pulse  is  gene- 
rally regular.  In  slight  cases  the  complexion  and  habit  of  the 
body  are  little  altered  ;  but  when  the  affection  is  more  consider- 
able, the  skin  usually  assumes  a  dull  earthy  hue,  with  a  slight 
shade  of  blue  here  ?nd  there.  The  lips  become  violet,  thick,  and 
look  swollen.  In  every  case  that  I  have  met  with,  there  existed 
an  habitual  cough.  Sometimes  this  was  infrequent,  slight,  and 
either  dry  or  attended  with  a  trifling  expectoration  of  a  very  vis- 
cid greyish  and  transparent  matter ;  at  other  times,  it  was  more 
severe,  returning  in  paroxysms,  and  accompanied  by  the  usual 
mucous  expectoration.  In  some  instances  the  patients  denied 
having  either  habitual  cough  or  expectoration  :  but  on  watching 
them  carefully,  it  was  found  that  they  coughed  slightly,  at  least 
once  or  twice  daily,  and  expectorated  every  morning  a  little  of 
the  viscid  bronchial  mucus  above  mentioned.* 

This  disease  begins  frequently  in   infancy,  and  may  continue  a 

fectly  free  in  the   intervals   of  the  asthma.     I  have,  however,  collected  •some 
examples,  and  M.  Louis  has  done  the  same. 

The  dyspnoea  depending  on  emphysema  of  the  lungs,  has  been  differently 
explained,  according  to  the  diversity  of  the  ideas  which  have  prevailed  respect- 
ing the  cause  of  the  disease  and  the  alterations  attending  it.  Laennec  accounts 
for  it  by  the  difficulty  encountered  in  the  passage  of  the  air  through  obstructed 
bronchi  into  the  vesicles.  M.  Louis  inclines  to  think  the  cause  exists  in  the 
thickening  of  the  walls  of  the  vesicles — a  thickening  which  he  regards  as 
almost  always  present,  and  which  hinders  the  air  from  coming  into  a  sufficiently 
close  contact  with  the  blood  to  vivify  it.  Regarding  emphysema  of  the  lungs 
as  the  frequent,  if  not  the  constant  effect  of  rarefaction  of  the  tissue  of  these 
organs,  I  account  for  the  dyspnoea  by  the  diminution  of  the  surface  over  which 
the  air  is  accustomed  to  expand  in  order  to  meet  and  renew  the  blood.  I  have 
in  a  previous  note,  explained  why  dyspnoea  is  not  so  generally  met  with  in  old 
persons  whose  lungs  are  thus  rarefied,  as  in  adults,  yet  in  many  of  these  aged 
persons  we  observe  an  anhelation  which  does  not  uniformly  depend  on  the  state 
of  the  heart,  but  is  often  owing  to  the  too  great  rarefaction  of  the  pulmonary 
tissue. — Andral. 

The  cough  is  often  very  slight  in  persons  laboring  under  pulmonary  em- 
physema, and  may  even  be  suspended  for  many  months.  When  it  reappears  or 
increases,  it  always  augments  the  dyspnoea.  But  a  circumstance  which  should 
not  be  overlooked  is,  that  in  a  great  number  of  cases,  the  difficulty  of  breathing 
appears  long  before  the  cough,  which  often  does  not  come  on  till  the  emphyse- 
ma is  far  advanced.  The  cough  cannot  be  ranked  among  the  constant  and 
necessary  symptoms  of  this  affection. 

The  cough  may  be  dry  or  attended  by  the  varieties  of  expectoration  here 
described  by  Laennec.  No  -one  of  these  varieties  is  characteristic:  they  are 
connected  with  the  catarrh  which  accompanies  the  emphysema.  I  have  never 
known  the  cough  to  be  attended  by  the  spitting  of  blood,  except  in  cases  where 
the  emphysema  was  complicated  with  tubercles.  M.  Louis,  likewise,  has  never 
seen  haemoptysis  in  a  case  of  simple  pulmonary  emphysema.—  Andral. 


EMPHYSEMA    OF    THE    LUNGS.  171 

great  many  years.  It  does  not  always  prevent  the  subjects  of  it 
from  attaining  an  advanced  age ;  although  it  must  be  admitted 
that  the  influence  it  may  have  in  unfavorably  modifying  other 
accidental  diseases,  must  very  considerably  diminish  the  proba- 
bilities of  life.  The  constant  and  frequently  very  great  efforts 
which  the  patient  is  obliged  to  make  during  respiration,  often,  at 
last,  give  rise  to  hypertrophy  or  dilatation  of  the  heart.* 

When  the  emphysema  is  confined  to  one  lung,  or  is  much 
greater  in  one  than  the  other,  the  side  most  affected  is  perceptibly 
larger  than  the  other ;  its  intercostal  spaces  are  wider ;  and  it 
yields  a  clearer  sound  on  percussion.  If  both  sides  are  affected 
equally,  the  whole  chest  yields  a  very  distinct  sound,  and  instead 
of  its  natural  compressed  shape,  it  exhibits  an  almost  round  or 
globular  outline,  swelling  out  both  before  and  behind.  This  con- 
formation of  the  chest  is  sufficiently  remarkable  to  have  enabled 
me  sometimes  to  announce  the  existence  of  emphysema  from  sim- 
ple inspection.! 

*  The  greater  part  of  those  attacked  by  pulmonary  emphysema  are  subjected, 
as  the  malady  advances,  to  palpitations,  which  by  degrees  increase,  but  which 
are  not  connected  at  the  outset  with  any  change  in  the  texture  of  the  heart. 

The  dyspnoea  always  precedes  by  some  years,  these  abdominal  palpitations : 
for  a  long  time  no  lesion  of  the  heart  can  be  discovered  even  by  auscultation ; 
but  at  a  later  period,  when  its  action  becomes  more  disturbed,  the  nutrition  of 
the  heart  undergoes  a  modification,  and,  as  Laennec  has  well  remarked,  its 
cavities  become  dilated  or  its  walls  thickened. 

There  are  many  organic  affections  of  the  heart  which  are  in  this  manner  the 
mechanical  result  of  the  influence  exercised  on  the  circulation  by  emphysema 
of  the  lungs.  M.  Louis  has  also  shown  that  the  heart  is  more  often  affected 
with  aneurism  during  the  existence  of  pulmonary  emphysema,  than  of  any 
other  disease.  There  is  no  comparison,  for  instance,  between  the  frequency  of 
the  diseases  of  the  heart  in  patients  who  labor  under  emphysema  of  the  lungs, 
and  the  frequency  of  the  same  diseases  in  those  who  have  tubercles  in  these 
organs.  It  is  vastly  greater  in  the  former  than  in  the  latter.  The  anasarcous 
condition  exhibited  by  many  patients  affected  with  emphysema  of  the  lungs,  is 
observed  only  in  those  whose  hearts  are  diseased.  It  cannot  be  ascribed  solely 
to  the  emphysema ; — and  in  persons  in  whom  it  occurs  without  any  symptoms 
of  organic  affection  of  the  heart,  the  cause  must  be  sought  for  in  some  other 
organ  than  the  lungs.  In  a  case,  for  example,  recently  under  my  notice,  the 
extensive  anasarcous  swellings  which  accompanied  emphysema  of  the  lungs, 
coincided  with  the  existence  of  that  particular  affection  of  the  kidneys  first 
noticed  by  Bright,  and  which  bears  his  name. — indral. 

t  Cases  in  which  a  general  dilatation  .of  the  chest  occurs,  are  less  common 
than  those  in  which  the  dilatation  is  confined  only  to  one  side.  In  the  latter 
instance,  the  form  of  the  chest  is  altered  in  front  from  the  clavicle  to  the  mam- 
ma or  a  little  below.  Throughout  this  extent,  the  surface  of  the  thorax  dis- 
plays a  convexity  much  more  prominent  than  on  the  opposite  side,  though  both 
sides  may  be  unusually  protuberant.  The  increase  of  convexity  corresponds 
with  the  ordinary  seat  of  the  pulmonary  emphysema,  for  it  is  along  the  anterior 
border  of  the  lungs  that  the  air  vesicles  are  most  inclined  to  dilatation — and  in 
these  portions  of  the  organs  are  found  most  commonly,  traces  of  emphysema. 

M.  Louis  has  recently  indicated  the  infra-clavicular  regions  as  being,  in  cases 
of  pulmonary  emphysema,  the  seat  of  a  prominence  which  forms  a  contrast  to 
the  depression  observable  above  and  behind  each  clavicle,  in  subjects  free  from. 
emphysema. 

This  prominence  has  been  noticed  by  M.  Louis  in  all  the  cases  he  has  search- 


172  EMPHYSEMA    OF    THE    LUNGS. 

The  pathognomonic  signs  of  this  disease  are  furnished  by  a 
comparison  of  the  indications  derived  from  percussion  and  me- 
diate auscultation.  The  respiratory  sound  is  inaudible  over  the 
greater  part  of  the  chest,  and  is  very  feeble  in  the  points  where 
it  is  audible :  at  the  same  time,  a  very  clear  sound  is  produced 
by  percussion.  From  time  to  time,  also,  we  perceive,  while  ex- 
ploring the  respiration  or  cough,  a  slight  sibilous  rhonchus  or 
sound  of  the  valve,  as  in  the  dry  catarrh,  occasioned  by  the  dis- 
placement of  the  pearly  sputa.  So  far,  indeed,  these  signs  are 
merely  those  formerly  described  as  indicating  the  dry  catarrh, 
to  which,  as  we  have  already  seen,  this  disease  is  almost  always 
owing.  In  doubtful  cases,  the  long  continuance  of  the  disorder, 
the  severity  of  the  habitual  dyspnoea,  and  the  asthmatic  par- 
oxysms occasionally  occurring,  will  suffice  to  point  out  the  ex- 
istence of  emphysema  in  some  parts  of  the  lungs.  These  indica- 
tions will  be  strengthened  by  the  existence  of  extreme  indistinct- 
ness of  the  respiratory  sound  generally,  and  by  its  entire  absence 
in  certain  points ;  characters  which  might  be  expected  to  be 
much  more  marked  in  this  affection,  than  in  the  simple  dry  ca- 
tarrh, owing  to  the  compression  of  the  neighboring  cells  by 
those  which  are  dilated.  The  cylindrical  form  of  the  chest,  and 
the  slight  lividity  of  the  skin,  will  also  help  the  diagnosis.  In 
the  case  of  one  lung  being  principally  affected,  the  augmented 
sonorousness  and  increased  size  of  this  side  will  discriminate 
the  disease  from  all  others,  except  pneumo-thorax,  from  which 
likewise,  as  will  be  shown  when  we  come  to  treat  of  that  disease, 
it  can  be  readily  distinguished.  When  existing  in  a  high  degree, 
this  disease  may,  in  the  last  place,  be  recognised  by  a  sign  which 
is  altogether  pathognomonic,  and  which  I  have  described  in  Part 
First  under  the  name  of  the  crepitous  rhonchus  with  large  bub- 
bles. In  this  case,  the  sound  during  inspiration  or  coughing,  is 
like  that  which  would  be  produced  by  blowing  into  half-dried  cel- 
lular substance.  It  differs  from  the  common  crepitous  rhonchus, 
in  conveying  the  notion  of  dryness,  and  also  as  being  connected 
with  bubbles  which  are  at  once  large  and  unequal,  the  other 
rhonchus  having  qualities  exactly  the  reverse.*     This  phenome- 

ed  for  it,  with  one  exception  :  he  has  never  met  with  it  except  in  those  afflicted 
with  emphysema  of  the  lungs.  My  own  observations  confirm  those  of  M. 
Louis.  The  inspection,  therefore,  of  the  infra-clavicular  regions  must  not  be 
neglected,  in  searching  for  proofs  of  the  existence  of  pulmonary  emphysema. 
Jindral. 

The  evidence  afforded  by  auscultation  in  cases  of  emphysema  of  the  lungs, 
is  not  of  the  same  nature  in  all  stages  of  the  disease.  When  the  patient  coughs 
but  little  or  none  at  all,  auscultation  affords  only  negative  evidence:  all  that 
can  be  heard  is  a  feeble  respiratory  murmur,  which  in  some  points  of  the  chest 
is  entirely  wanting.  On  the  other  hand,  when  the  patient  has  caught  a  new 
cold,  and  is  attacked  by  one  of  those  fits  of  asthma  from  which  he  is  so  rarely 
exempt,  auscultation  detects  in  many  points  the  existence  of  several  rhonchi, 


EMPHYSEMA  OF  THE  LUNGS.  173 

non  is  however  not  common,  and  when  it  exists,  it  is  of  very  short 
duration,  and  is  observed  only  in  points  of  small  extent.  It  is 
much  more  common  and  more  permanent  in  the  interlobular  em- 
physema. In  some  instances  the  patients  have  been  sensible  of  a 
crackling  in  the  spot  where  this  rhonchus  was  heard ;  and  still 
more  rarely  I  have  perceived,  in  thin  subjects,  a  crepitation  in  the 
same  place,  when  pressing  it  externally  with  the  finger.* 

Progress  of  the  disease.  The  organic  lesion  at  present  under 
consideration  commonly  follows  an  attack  of  acute  dry  catarrh 
when  supervening  to  a  chronic  affection  of  the  same  kind  ;  and 
the  repeated  return  of  these  acute  attacks,  gives  rise  to  most  of 
the  cases  of  dry  asthma.  Asthmatic  paroxysms  of  this  kind  are 
accompanied  by  an  extreme  oppression,  which,  however,  does 
not  always  prevent  the  patient  from  assuming  the  horizontal 
posture.  If  fever  accompanies  the  attack  of  catarrh,  the  oppres- 
sion becomes  less  ;  and  if  a  little  pituitous  or  mucous  expectora- 
tion comes  on,  the  asthmatic  paroxysm  soon  terminates,  and  the 
breathing  becomes  sometimes  freer  than  before :  in  this  case  it 
would  seem  as  if  the  viscid  mucus  which  usually  obstructs  the 
bronchi,  became  less  tenacious,  or  was  carried  off  by  the  more 
liquid  and  less  adhesive  secretion  produced  by  the  recent  ca- 
tarrh. If,  on  the  other  hand,  the  recent  catarrh  brings  no  alle- 
viation, the  asthmatic  attack  is  of  long  continuance,  and  the 
patient  only  slowly  returns  to  his  ordinary  state,  and  even  not 
unfrequently  remains  more  habitually  oppressed  than  before. 
The  severer  asthmatic  paroxysms  occur  only  after  very  long  in- 
tervals, during  the  first  years  of  the  disease  ; — the  greater  number 
of  the  catarrhal  affections  producing  merely  a  slight  and  tempo- 
rary increase  of  the  usual  dyspnoea.  But  when  the  complaint  is 
of  long  standing  and  the  patients  far  advanced  in  life,  the  par- 
oxysms become  more  frequent  and  severe.  Each  succeeding 
attack  increases  the  extent  of  the  organic  lesion  ;  and  rupture  of 
the  pulmonary  tissue,  and  sometimes  interlobular  emphysema, 
then  ensues. 

From  the  preceding  observations  it  must  be  concluded,  that 

especially  the  sibilous,  the  dry  sonorous,  and,  less  commonly,  the  sub-crepitous. 
These  rhonchi  alone  would  not  be  sufficient  evidence  of  emphysema,  for  they 
are  also  heard  in  many  other  complaints,  and  are  the  consequence  of  an  affec- 
tion of  the  bronchi  which  is  connected  with  a  disease  of  the  vesicles. — flridral. 
*  The  circumstances  mentioned  in,  the  text,  coupled  with  the  fact  that  it  is 
heard  continuously  in  the  interlobular  emphysema,  clearly  demonstrate  that  the 
dry  crepitous  rhonchus  or  crackling,  only  exists  at  the  moments  of  rupture  of  the 
air  cells  ;  and  it  is  extremely  probable  that  it  is  produced  by  this  accident  and 
the  consequent  extravasation  of  the  air  into  the  surrounding  cellular  substance. 
It  is,  however,  by  no  means  allowable  to  explain,  in  the  same  manner,  the  ob- 
scure sihilous  rhonchus  or  sound  of  the  valve  or  click,  also  perceptible  in  the 
pulmonary  emphysema;  as  this  admission  would  necessarily  involve  the  belief 
of  the  laceration  of  the  air  cells  in  the  case  of  catarrhs,  in  most  of  which  this 
clicking  is  perceptible  at  their  onset. — (M.  L.) 


174  EMPHYSEMA  OF  THE  LUNGS. 

pulmonary  emphysema,  in  a  middling  degree,  is  not  a  disease  of 
great  severity.  Of  all  the  varieties  of  asthma  it  is  unquestion- 
ably that  which  affords  to  the  patient  the  best  prospect  of  long 
life.  The  long  continuance  and  slow  progress  of  the  disease  and 
the  nature  of  its  causes,  render  it  possible  to  struggle  against 
the  organic  lesion,  and  permit  the  functional  disorders  resulting 
from  it  to  be  kept  within  tolerable  bounds.* 

*  In  Sir  John  Floyer's  "  Treatise  of  the  Asthma,"  London,  1698,  referred  to 
in  a  preceding  page,  there  is  a  fuller  and  more  distinct  account  of  the  organic 
lesion  treated  of  in  this  chapter,  than  our  author  seems  to  be  aware  of.  It  is 
true,  the  lungs  examined  by  Sir  John  were  those  of  a  mare,  but  he  evidently 
considers  the  remarks  he  makes,  as  applicable  to  the  human  subject.  Contrary 
to  the  assertion  of  Laennec,  this  author  expressly  notices  the  dilatation  of  the 
air  cells;  and  in  several  passages  (see  p.  240-247)  he  seems  to  entertain  ideas 
relative  to  the  causes  and  effects  of  this  lesion  very  similar  to  those  of  M.  Laen- 
nec. Sir  John  notices  the  same  affection  as  existing  in  hawks,  and  being  the 
cause  of  the  disease  in  them  termed  the  crocke,  a  kind  of  dyspncea  produced  by 
overstraining  in  flying,  (Phys's.  pulse  watch,  vol.  ii.  p.  400.)  Making  allowan- 
ces for  the  antiquated  phraseology,  the  following  piece  of  pathology  comes  very 
near  our  author's  :  "  As  it  happens  jn  external  flatulent  tumours,  they  at  first 
go  off  and  return,  but  at  last  fix  in  permanent  flatulent  tumours  ;  so  it  is  in 
the  flatulent  asthma,  the  frequent  nervous  inflations  induce  at  last  a  constant 
windy  tumour  or  inflation  ;  and  it  ought  to  be  considered  how  far  holding  the 
breath  in  hysteric  fits,  or  the  violent  coughing  in  long  catarrhs,  or  the  great  dis- 
tention of  the  lungs  by  an  inflammation,  may  strain  the  bladders,  and  their  mus- 
cular fibres,  and  thereby  produce  the  same  rupture,  or  dilatation,  or  hernia,  as 
happens  in  the  broken-winded.  This  must  be  observed  by  the  help  of  the  mi- 
croscope ;  and  if  the  air  blown  into  the  lobe  will  not  be  expelled  thence  by  the 
natural  tone  or  muscle  of  the  bladders,  that  the  lobe  may  again  subside  of  itself, 
'tis  certain  some  injury  is  done  to  the  ventiducts  ;  the  bladders  are  either  brok- 
en, and  admit  the  air  into  the  membranous  interstices,  or  else  they  are  over- 
distended,  like  a  hernia  in  the  peritoneum  ;  and  this  will  produce  an  inflation 
of  the  whole  substance  of  the  lungs,  and  that  a  continual  compression  of  the  air 
and  blood-vessels,  which  will  produce  a  constant  asthma." — (Treatise  on  Asth- 
ma, p.  244.) — Pulmonary  emphysema  is  noticed  in  the  recorded  dissections  of 
many  of  the  older  authors.  I  will  here  refer  to  a  few  :  Bonetus,  Sepulchret, 
lib.  ii.  sect.  i.  obs.  54,55,  56,  57,  58  ;  Ruysch,  obs.  19,  21  ;  Morgagni,  Ep.  iv  24. 
xviii.  14;  Ridley,  obs.  p.  219—234,  Lond.  1763;  Sir  W.  Watson,  Phil.Tr.  Abr. 
xii.  145  ;  Heberden    Comment,  p.  63. 

It  is  evident  that  the  disease  in  horses  termed  broken  wind,  as  we  find  it  de- 
tailed in  our  best  veterinary  works,  is  precisely  the  same  organic  lesion  as  that 
described  in  the  text;  although  I  have  not  met  with  any  one,  except  Floyer, 
who  noticed  the  dilatation  of  the  cells.  In  an  article  on  "  Broken-wind"  in 
Rees's  Cyclopedia,  the  disease  is  well  described,  and  the  morbid  condition  of 
the  lung  is  there  termed  emphysema.  Several  dissections  of  this  disease  are 
given  in  Mr.  Percivall's  "  Lectures  on  the  Veterinary  Art ;"  and  in  one  of  these 
the  author  states  that  "  the  bronchial  and  tracheal  membranes,  though  of  their 
natural  color,  were  much  thickened  ;"  and  justly  adds,  that  if  this  appearance  is 
constant,  it  will  throw  much  light  on  the  pathology  of  broken-wind.  (vol.  ii.  p. 
357.) — The  pathology  of  broken-wind  in  horses,  has  been  since  more  accurately 
investigated  by  Andral.  His  examinations  of  lungs  in  this  state  have  presented 
to  him  the  three  species  of  lesion  described  by  Laennec — 1,  simple  dilatation  of 
the  small  bronchi  and  air  cells  ;  2,  rupture  of  the  walls  of  these  ;  3,  infiltration 
of  the  air  into  the  interlobular  cellular  tissue  ; — each  being  the  consequence  of 
the  other  in  the  order  stated.  M.  Andral  very  naturally  asks,  may  not  the  pul- 
monary emphysema  be  produced  in  the  same  mechanical  manner  in  man  from 
severe  and  long-continued  coughs?  may  not  the  temporary  distention  of  the  air 
cells  by  air  or  mucus  give  rise  to  their  permanent  dilatation  ?  and  replies— that 
all  that  is  necessary  to  insure  this  result  is  that  the  elastic  power  naturally  inhe- 


EMPHYSEMA    OF    THE    LUNGS. 


175 


.Treatment.  Emphysema  of  the  lungs  being  almost  always 
the  consequence  of  the  dry  catarrh,  presents  the  same  indications 
of  cure  as  were  pointed  out  when  treating  of  that  disease.  Fric- 
tions with  oil  are  often  very  useful  in  lessening  the  susceptibility 
to  be  affected  by  catarrh.  In  the  case  of  pallid  cachectic  sub- 
jects, the  subcarbonate  of  iron  has  occasionally  seemed  to  have 
a  similar  effect,  and  to  tend  at  the  same  time,  to  diminish  the 
congestion  of  the  mucous  membrane,  and  also  the  spasmodic 
stricture  of  the  bronchi.  In  the  severer  asthmatic  paroxysms,  it 
is  frequently  necessary  to  have  recourse  to  venesection,  in  order 
to  relieve  the  congestion  of  blood  in  the  lungs ;  and  it  is 
always  proper  to  diminish  the  necessity  of  respiration  by  means 
of  narcotics.* 

The  following  cases  will  furnish  examples  of  most  of  the  facts 
stated  in  the  preceding  pages  : 

Case  V. — Partial  emphysema  of  the  lungs.  A  woman,  aged 
fifty,  came  into  the  Necker  Hospital  in  December  1818,  affected 
with  great  dyspnoea,  cough,  strong  action  of  the  heart,  anasarca 
of  the  extremities,  &c.  which  were  said  to  have  existed  three 
weeks.  She  died  the  same  night.  On  examination,  the  lungs 
were  found  free  from  adhesions,  voluminous,  and  lighter  than 
usual.  A  large  portion  of  the  right  lung  and  almost  all  the 
lower  lobe  of  the  left,  were  smooth  and  shining,  yet  somewhat 
irregular  on  the  surface  ;  and  they  collapsed  much  less  than  the 
other  parts.  On  the  surface  of  these  portions  there  was  a  great 
number  of  transparent  vesicles,  of  the  size  of  a  millet  or  hemp- 
seed,  and  some  as  large  as  cherry-stones  ;  the  former  being  level 
with  the  general  surface,  the  latter  somewhat  prominent.  Upon 
inspecting  these  vesicles  closely,  they  were  found  to  be  the  air 
cells  in  a  state  of  dilatation.  The  cells  around  these,  and  indeed 
over  the  whole  of  the  lung  that  remained  uncollapsed,  were  more 
distinct  than  is  usual,  and  gave  the  parts  so  affected  a  resem- 
blance to  the  vesicular  lungs  of  cold-blooded  animals.  In  two 
or  three  points  there  were  bubbles  of  air  of  the  size  of  a  small 
filbert,  extravasated  beneath  the  pleura.  These  were  readily 
distinguished  from  the  dilated  cells,  by  being  easily  displaced  by 

rent  in  the  air  cells  should  be  overcome  and  destroyed.     (Precis  a"  Jinat.  Pathol. 
t.  ii.  p.  526.)     These  views  accord  precisely  with  those  of  Laennec. —  Transl. 

*  The  following  notable  proposal  for  curing  emphysema  of  the  lungs,  seems 
worthy  of  record  in  this  place,  as  a  striking  illustration  of  the  absurdities  into 
which  even  the  most  sensible  practitioners  could  be  led,  before  the  physical  re- 
searches of  the  moderns  had  redeemed  pathology  from  the  dominion  of  meta- 
physical theory  :  "  The  cure  of  the  broken  wind,"  says  Sir  John  Floyer,  "  can- 
not easily  be  projected  any  other  way  but  by  a  paracentesis  in  the  thorax  ;  for  if 
the  external  air  be  admitted,  it  will  compress  the  flatulent  tumor,  and  through 
the  same  hole  a  styptic  and  carminative  hydromel  may  be  injected,  to  restore  by 
its  stypticity  the  tone  of  the  membranes,  and  discuss  by  its  aromatic  acrimony  the 
windy  spirits,  or  air  retained  in  the  lungs."—  Treatise  of  the  .isthma,  p.  246. — 
Transl. 


176  EMPHYSEMA  OF  THE  LUNGS. 

pressure.  On  compressing  these  portions  of  the  lungs  where  the 
cells  were  dilated,  the  resistance  afforded  by  them  was  softer,  and 
the  sensation  communicated,  was  unlike  the  natural  crepitation 
usually  perceived.  The  air  in  escaping  from  these  parts  pro- 
duced a  gentle  hissing.  On  puncturing  them  they  collapsed, 
and  lost  the  appearance  above  described.  In  other  respects,  the 
substance  of  the  lungs  was  sound.  The  bronchi,  particularly  the 
smaller  branches,  in  the  affected  parts,  were  perceptibly  dilated, 
of  a  deep  red  color,  and  filled  with  a  very  viscid  and  nearly 
colorless  mucus. 

Case  VI. — General  emphysema  of  the  lungs.  J.  B.  Cocard, 
aged  37,  came  into  the  Necker  Hospital  in  May  1817.  He  had 
been  subject  to  habitual  cough,  and  mucous  expectoration,  ever 
since  he  was  three  years  old.  He  had  likewise  dyspnoea,  but 
never  sufficient' in  the  earlier  part  of  his  life,  to  prevent  him  from 
following  his  occupations  as  a  laborer,  except  in  winter,  when 
he  was  always  confined  to  bed  for  some  days,  on  account  of  the 
increase  of  his  cough.  In  his  thirty-third  year,  he  had  haemop- 
tysis, which  had  no  further  immediate  consequences  ;  and  it  was 
not  till  three  years  afterwards  that  dropsical  symptoms  made 
their  appearance.  When  he  came  into  the  hospital,  on  the  25th 
of  May,  there  was  anasarca  of  the  abdomen  and  lower  extremities, 
the  lips  were  bluish,  the  respiration  short  and  much  oppressed, 
frequent  cough,  with  pituitous  expectoration,  pulse  frequent,  and 
regular,  and  the  skin  of  natural  temperature.  The  chest  sounded 
every  where  very  well.  The  sound  of  respiration  could  be  per- 
ceived with  difficulty  immediately  below  the  clavicles,  and  was 
altogether  imperceptible  over  the  remaining  parts  of  the  chest ; 
except  that,  now  and  then,  one  could  for  a  moment  fancy  that 
he  heard  it,  at  which  times  it  was  accompanied  by  a  slight 
sibilous  rhonchus,  like  the  clicking  of  small  valves  placed  in  the 
bronchi.  The  chest,  both  before  and  behind,  was  remarkably 
rounded  and  prominently  arched.  The  heart  yielded  both 
a  slight  impulse  and  sound.  After  a  short  stay  in  the  hos- 
pital, the  dropsical  symptoms  were  removed,  and  he  went  out 
on  the  9th  of  June.  On  the  first  of  the  following  month, 
however,  he  returned,  in  the  same  state  as  when  first  admitted. 
At  this  time,  I  was  led  from  considering  as  well  the  symptoms 
present,  as  the  absence  of  others,  and  from  comparing  the  case 
with  some  which  I  had  recently  seen,  to  come  to  the  conclusion 
that  the  disease  was  general  emphysema  of  both  lungs.  The  drop- 
sical state  was  again  relieved  by  diuretics,  and  he  left  the  hospital 
on  the  19th,  affected  merely  with  his  habitual  cough  and  dyspnoea. 
During  the  whole  time  he  remained  in  the  hospital,  the  stetho- 
scope never  detected  the  sound  of  respiration,  except  very  feebly 
in  a  few  varying  points  of  the  chest,  particularly  between  the 


EMPHYSEMA    OF    THE    LUNGS. 


177 


clavicle  and  third  rib.  This  man  returned  once  more  to  the 
hospital  in  September,  with  the  pectoral  symptoms  as  before, 
and  with  the  addition  of  severe  diarrhoea.  He  was  getting  better 
of  this,  when  he  was  seized  with  small-pox,  and  died  about  three 
weeks  aften  his  admission  into  the  hospital. 

Dissection  twenty-four  hours  after  death.  The  heart  was 
double  its  natural  size,  both  ventricles  being  dilated,  and  thick- 
ened. Both  lungs  were  found  without  any  adhesions,  filling 
completely  the  cavity  of  the  chest,  and  not  at  all  collapsing  on 
the  admission  of  the  external  air.  Their  surface  was  smooth, 
shining,  drier  than  natural,  and  seemingly  unctuous.  The  upper 
lobes  presented  on  their  surface  some  transparent  vesicles,  vary- 
ing in  size  from  that  of  a  filbert  to  that  of  an  almond,  and  even 
a  walnut,  and  evidently  produced  by  the  extravasation  of  air  under 
the  pleura.  The  specific  gravity  of  the  lungs  was  at  least  one- 
half  less  than  natural.  ■  When  placed  in  water,  they  hardly 
dipped  even  a  few  lines  into  the  fluid.  When  compressed  in 
•the  hand,  the  sensation  communicated  was  rather  that  of  the  dis- 
placement of  an  elastic  fluid,  than  the  natural  crepitation  of  the 
viscus.  When  cut  into,  the  air  made  its  escape  with  a  slight 
hissing.  The  substance  of  the  lungs  was  drier  than  natural,  ex- 
cept in  some  spots  near  their  centre  and  roots^  which  were  less 
emphysematous,  and  from  which  there  flowed  a  little  frothy  and 
bloody  serum.  The  pulmonary  substance  was  in  other  respects 
sound.* 

Case  VII. — Slight  emphysema, — suffocative  catarrh  and 
slight  peripneumony.  A  man,  of  delicate  health  in  childhood,  and 
affected  with  spinal  curvature,  in  his  twenty-eighth  year  became 
subject. to  slight  cough  and  habitual  dyspnoea.  Two  years  after- 
wards he  caught  a  severe  cold,  with  much  aggravation  of  his 
former  symptoms,  and  came  into  the  hospital  in  January.  At  this 
time  the  following  report  was  made  of  the  case :  Thorax  promi- 
nently arched  and  almost  cylindrical  anteriorly;  the  patient 
keeping  himself  nearly  in  a  sitting  posture  in  bed ;  the  trunk 
inclined  forwards ;  heat  of  skin  moderate ;  respiration  high  and 
short ;  cough  in  fits ;  expectoration  of  a  ropy  frothy  mucus ; 
cheeks,  lips  and  nails  of  a  violet  color.  The  chest  yielded  a 
very  clear  sound  throughout,  except  on  the  lower  part  of  the 
right  side  behind,  where  there  was  hardly  any.  The  respiration 
was  just  barely  perceptible  over  the  whole  left  side,  and  was  ac- 
companied with  a  slight  degree  of  rhonchus,  sometimes  mucous 

*  The  state  of  the  air  cells  is  not  noticed  in  this  case,  the  gentleman  who 
made  the  examination  being  at  the  time  unacquainted  with  this  particular  lesion. 
Upon  being  shown  afterwards  lungs  decidedly  emphsematous,  he  admitted  that 
they  exhibited  a  precisely  similar  appearance  to  those  in  the  present  subject. — 
Author. 

■23 


178  EMPHYSEMA  OF  THE  LUNGS, 

and  sometimes  sibilous.  The  upper  part  of  the  right  side  afford- 
ed the  same  results;  but  on  the  lower  part,  there  was  a  slight 
crepitous  rhonchus  without  any  of  the  natural  sound  of  respira- 
tion. The  pulsations  of  the  heart  were  feeble  and  indistinct. 
The  pulse  was  weak,  not  very  quick,  and  slightly  intermittent. 
The  external  jugulars  were  swollen  but  without  pulsation.  Di- 
agnosis :  Emphysema  of  the  lungs,  with  suffocative  catarrh 
and  slight  peripneumony  of  the  lower  part  of  the  right  lung. 
He  died  on  the  following  day. 

Dissection  thirty-six  hours  after  death.  The  left  lung  filling 
completely  the  cavity  of  the  chest,  and  projecting  beyond  the 
mediastinum,  yielding  to  the  touch  a  sensation  intermediate  be- 
tween that  afforded  by  a  bladder  half  filled  with  air,  and  the 
natural  crepitation  of  the  healthy  viscus.  The  air  cells,  evi- 
dently enlarged  over  the  whole  surface  of  the  lung,  had  the  same 
appearance  to  the  naked  eye  as  the  healthy  cells  present  under 
the  microscope,  the  largest  being  of  the  size  of  a  grape-stone, 
and  the  smallest  of  the  size  of  a  millet-seed.  Their  shape  was 
globular  or  ovoid.  On  different  points  of  the  surface  there  were 
also  many  small  extravasations  of  air  beneath  the  pleura,  three  or 
four  times  as  large  as  the  dilated  cells,  but  not  more  prominent 
than  them.  On  outting^into  them,  they  were  found  capable  of 
containing  a  hemp-seed  or  even  a  cherry-stone.  The  substance 
of  the  lungs  was  less  crepitous  than  natural,  when  cut  into,  and 
was  extremely  dry.  The  bronchi  were  larger  than  natural,  very 
red,  and  filled  with  white  ropy  mucus.  The  right  lung  exhibited 
the  same  appearances  as  the  left,  in  the  upper  and  middle  lobes ; 
but  the  lower  lobe  was  indurated,  and  posteriorly  it  was  as  hard 
as  liver.  In  this  point  it  was  of  a  violet  red  color,  intermixed 
with  yellowish  spots,  and  looked  granular  when  incised.  Above 
this  spot,  and  anteriorly,  it  was  still  somewhat  crepitous,  though 
much  gorged  with  blood  and  sanies.  The  other  organs  were 
sound. 

Case  VIII. — Emphysema,  with  rupture  of  the  pulmonary 
substance,  in  a  patient  long  cured  of  phthisis.  A  woman,  aged 
52,  had  been  affected  for  the  last  eighteen  years  with  dispnoea, 
habitual  cough,  attended  with  little  expectoration,  but  often  so 
severe  as  to  prevent  sleep.  She  had  never  been  prevented  from 
following  her  occupation  until  the  period  of  her  entry  into  the 
hospital.  At  this  time  there  was  considerable  emaciation,  com- 
plete incapacity  to  lie  in  the  horizontal  posture,  respiration  short 
and  difficult,  very  frequent  and  severe  cough,  of  a  convulsive 
character,  like  that  of  the  hooping  cough,  with  mucous  expec- 
toration, pulse  quick,  and  skin  of  the  natural  temperature.  The 
chest  sounded  well  on  percussion,  but  respiration  was  inaudible 
in  the  greater  part  of  it.     Pectoriloquy  was   perfect  above  the 


EMPHYSEMA    OF    THE    LUNGS.  H9 

right  clavicle,  and  doubtful  at  the  roots  of  both  lungs.  I  caused 
the  following  diagnosis  to  be  recorded  :  Excavation  in  the  top  of 
the  right  lung,  dilatation  of  the  bronchi,  particularly  of  the 
larger  trunks.  It  was  to  this  last  that  I  attributed  the  doubtful 
pectoriloquy  towards  the  roots  of  the  lungs.  The  state  of  the 
respiration,  the  comparison  of  the  signs  furnished  by  percussion 
and  the  stethoscope,  and  the  whole  symptoms  taken  together, 
indicated  also  emphysema  of  the  lungs  ;  but  surprised  at  the 
great  number  of  cases  in  which  I  had  recently  met  with  symp- 
toms of  this  affection,  I  was  unwilling  to  come  to  a  decided 
opinion  respecting  its  existence  in  the  present  case,  without  fur- 
ther examination, — and  the  more  so,  as  the  dilatation  of  the 
bronchi,  which  was  supposed  to  exist,  if  found  to  be  general 
over  the  lungs,  might,  by  compressing  the  air  cells,  render  the 
sound  of  respiration  very  indistinct.  This  woman  died  three 
days  after  her  admission. 

Dissection  thirty-six  hours  after  death.  Both  lungs  were  found 
adhering  strongly  to  the  ribs  by  old  attachments.  The  upper 
lobe  of  the  left  lung  was  divided  into  two  by  a  natural  intersec- 
tion, the  superior  division  being  entirely  covered  with  semi-trans- 
parent vesicles,  slightly  prominent,  and  varying  in  size  from  that 
of  a  hemp-seed  to  a  cherry-stone.  These  vesicles  were  evidently 
dilated  air-cells,  and  covered  more  than  two  thirds  of  the  super- 
numerary lobe.  The  cells  between  these  were  also  dilated,  but 
in  a  less  degree,  being  about  the  size  of  a  millet-seed.  There 
were  likewise  two  vesicles  .of  the  shape  and  size  of  peas,  quite 
prominent  on  the  surface,  and  with  a  sort  of  neck  by  which  they 
were  attached  to  the  lung.  Upon  cutting  into  these,  it  was 
found  that  their  cavity  extended  within  the  pulmonary  substance 
about  a  line,  and  was  there  seen  communicating  with  the  adjoin- 
ing cells.  Over  nearly  all  the  rest  of  this  lung,  the  dilatation  of 
the  cells  was  very  conspicuous,  though  in  a  less  degree  than  in 
the  place  just  mentioned.  Almost  all  of  them  were  capable  of 
containing  a  millet-seed,  and  a  few  of  them  would  have  received 
a  hemp-seed  or  small  pea.  In  different  points  on  the  surface  of 
this  lung,  there  were  also  four  or  five  protuberances  of  an  irregu- 
lar oval  form,  and  of  the  size  of  an  almond,  corresponding  to 
excavations  situated  two  or  three  lines  deep  in  the  lung,  and 
which  were  produced  by  laceration  of  its  substance.  These 
cavities, — of  which  the  largest  might  have  contained  a  middling- 
sized  walnut,  and  the  smallest  a  filbert, — were  full  of  air,  and 
collapsed  on  being  cut  into.  The  internal  surface  of  two  of 
these  were  tinged  with  blood,  and  one  of  them  contained  a  small 
clot  of  blood,  one-fourth  of  its  own  size.  The  walls  of  the  others 
were  of  the  natural  color  of  the  lung,  and  presented  a  layer  of 
ruptured  and  compressed  cells,  to  the  depth  of  a  line  and  a  half. 


180  EMPHYSEMA    OF    THE    LUNGS. 

Beyond  this  depth,  on  all  sides,  the  cells  were  distended  beyond 
their  natural  size.  It  is  to  be  remarked  that  the  ruptured  por- 
tions did  not  exist  in  any  place  at  a  greater  depth  under  the  sur- 
face than  an  inch,  and  that,  below  this,  the  emphysematous  dila- 
tation of  the  cells  was  not  very  distinguishable.  It  was  equally 
evident  that  the  cells  in  the  vicinity  of  these  lacerations  were 
neither  larger  nor  more  numerous  than  elsewhere,  and  that  there 
was  no  infiltration  or  extravasation  of  air  into  the  inter-alveolar 
tissue.  The  right  lung  exhibited,  but  in  a  lesser  degree,  the 
same  dilatation  of  the  cells,  but  no  rupture  of  substance.  In  the 
upper  and  posterior  part  of  this  lung,  however,  there  was  found 
an  excavation  of  an  oval  shape,  about  two  inches  in  length, 
fifteen  lines  broad  in  its  centre,  and  two  lines  deep.  The  inner 
surface  of  this  cavity  was  smooth  and  polished,  though  somewhat 
irregular  ;  it  was  white,  but  interspersed  with  red  specks  arising 
from  numerous  small  vessels.  It  contained  some  small  fragments 
of  an  opaque,  very  dry,  semi-friable  matter,  of  a  pale  ochre- 
yellow  color,  and  attached  to  the  walls  of  the  cyst.  Three  bron- 
chial tubes  of  the  size  of  a  goose-quill  terminated  with  open 
mouths  in  this  cavity.  Their  coats  were  continuous  with  its  walls, 
and  their  communication  with  their  trunks  was  quite  free. 

The  cases,  of  which  I  have  now  given  an  account,  exhibit  ves- 
icular emphysema  of  the  lungs  in  its  different  degrees.  The  last 
case  gives,  further,  an  example  of  a  cure  of  what  is  usually  called 
an  ulcer  of  the  lungs,  the  true  nature  of  which  we  shall  see  here- 
after when  treating  of  phthisis.* 

Sect.  II.  Interlobular  emphysema. 

The  pulmonary  or  vesicular  emphysema,  as  we  have  just  seen, 
is  a  disease  essentially  chronic ;  that  which  I  am  now  going  to 
describe,  on  the  contrary,  is,  in  most  cases,  a  real  traumatic  lesion, 
almost  suddenly  produced.  This  is  the  emphysema  admitted  by 
surgeons  ;  universally  admitted,  indeed,  yet  very  little  known  accor- 
ding to  its  true  anatomical  characters.  This  is  so  much  the  case, 
that  I  do  not  know  where  any  exact  description  of  it,  drawn  from 
nature,  is  to  be  found. 

Anatomical  characters.      This  affection  is  characterised  by 

*  Vesicular  emphysema  of  the  lungs  is  a  much  more  frequent  disease  than  is 
commonly  imagined.  I  meet  with  it  constantly  in  practice,  in  some  intermedi- 
ate degree  between  what  may  be  called  its  first  stage,  the  dry  catarrh,  and  its 
complete  development  in  many  cases  of  prolonged  asthma.  There  is  no  disease 
which  illustrates  the  importance  and  necessity  of  percussion  more  than  this  ;  as 
without  its  simultaneous  employment,  the  stethoscope  will,  in  many  cases,  lead 
to  great  errors  of  diagnosis.  The  outlines  of  the  two  cases  of  this  disease  are 
given  in  my  work  entitled  "  Original  Cases,"  &c.  p.  271-3  ;  and  I  could  here 
add  many  more,  but  deem  it  unnecessary,  as  they  tend  to  the  same  results  pre- 
cisely as  are  exhibited  in  the  text.—  Transl. 


EMPHYSEMA    OF    THE    LUNGS.  181 

infiltration  of  air  between  the  lobules  of  the  lung.  The  texture 
of  the  cellular  partitions  which  constitute  the  intersecting  planes 
separating  these  lobules  from  each  other,  is  so  compact,  that  I 
doubted,  a  few  years  ago,  the  possibility  of  an  infiltration  of  air 
within  their  substance  ;*  but  I  have  since  that  time,  met  with 
several  examples  of  the  kind.  The  partitions  in  a  state  of  em- 
physema, instead  of  the  scarcely  perceptible  thinness  natural  to 
them,  present  a  thickness  varying  from  one  line  to  six,  or  nearly 
an  inch  in  some  instances.  And  in  place  of  their  usual  white- 
ness and  opacity,  they  exhibit  on  the  surface  of  the  lung,  and 
towards  its  edges  principally,  transparent  bands,  which  form  a 
marked  contrast  with  the  opaque  pulmonary  substance.  These 
bands  are  very  exactly  circumscribed,  and  upon  examination 
are  found  to  intersect  the  lung  through  its  whole  thickness,  or 
at  least  to  penetrate  deeply  into  its  substance.  The  want  of 
color  and  transparency  of  these  bands  is  owing  to  the  very  thin 
and  half-dried  condition  of  the  cellular  tissue  within  which  the 
air  is  extravasated.  The  emphysematous  partitions  are  usually 
wider  on  the  surface  of  the  lungs,  and  gradually  get  thinner  as 
they  approach  the  centre  ;  and,  in  this  respect,  they  may  be 
compared  to  the  segments  of  an  orange,  which  we  may  imagine 
to  contain  air  instead  of  the  pulpy  juice  of  the  fruit.  Sometimes 
several  bands  run  parallel  to  each  oiher,  containing  perfectly 
sound  portions  between  them.  More  rarely,  the  infiltrated  band 
runs  transversely,  and  thus  by  intersecting  several  of  the  vertical 
bands,  one  or  more  of  the  pulmonary  lobules  become  completely 
insulated.  Pretty  often  we  observe  along  the  course  of  the  vessels, 
particularly  those  on  the  surface,  bubbles  of  air  extravasated 
into  the  surrounding  cellular  substance,  somewhat  like  a  string 
of  beads ;  and  in  this  variety,  much  more  frequently  and  plenti- 
fully than  in  the  vesicular  emphysema,  we  find  bubbles  of  air 
beneath  the  pleura.  When  the  extravasation  exists  near  the 
roots  of  the  lungs,  it  speedily  extends  to  the  mediastinum,  and 
from  thence  crosses  to  the  neck  and  over  the  whole  subcutaneous 
and  intermuscular  cellular  substance  of  the  body. 

Although  we  must  consider  this  affection  as  necessarily  de- 
pending on  a  rupture  of  some  of  the  air-cells  in  the  first  place, 
and  the  consequent  extravasation  of  the  air  contained  in  them, 
into  the  cellular  substance  surrounding  the  lobules,  yet  we  are 
unable  to  detect  any  actual  rupture  of  the  cells,  and,  indeed, 
can  rarely  observe  any  dilatation  of  these.  Even  the  cells  of 
those  lobules  which  are  entirely  isolated  by  the  extravasation, 
are  in  a  perfectly  sound  state. 

To  have  a  correct  conception  of  the  anatomical  characters  of 

*  First  Edition,  torn.  ii.  page  213. 


182  EMPHYSEMA    OF    THE    LUNGS. 

the  interlobular  emphysema,  wc  must  inflate  the  lung,  pass  ;i 
ligature  above  the  affected  part,  and  then  dry  it  in  the  open  air. 
If  we  then  cut  the  preparation  by  slices,  we  observe  the  inter- 
lobular cellular  substance,  consisting  of  a  set  of  very  hue  plates, 
perfectly  transparent,  and  crossing  each  other  in  all  directions,  so 
as  to  leave  a  series  of  intervening  cells  of  unequal  shape  and  size 
and  all  communicating  with  each  other.  I  have  already  ob- 
served that  the  cells  of  the  insulated  lobules  are  in  a  sound 
state :  and  it  is  further  remarkable,  that  if  there  happens  to  be 
an  accumulation  of  blood  in  the  part,  from  mechanical  subsidence 
after  death,  the  lobules  are  alone  charged  with  it,  the  intersecting 
emphysematous  bands  being  quite  free  from  it. 

I  do  not  affirm  positively  that  the  emphysematous  affection  of 
the  cellular  partitions  never  extends  to  the  lobules  themselves  ; 
on  the  contrary,  it  seems  probable  in  the  case  of  very  large  infil- 
trations, that  some  intermediate  lobules  may  have  been  obliterated  ; 
I  must  say,  however,  that  I  never  could  perceive  any  thing  of  the 
kind,  in  my  researches. 

Occasional  causes.  The  most  common  of  these  is  the  pro- 
longed forcible  retention  of  the  breath  during  powerful  and  long- 
continued  exertions,  as  in  child-bed,  in  relieving  the  bowels  when 
constipated,  and  particularly  in  raising  heavy  weights.  Children 
are  more  subject  to  this  disease  than  adults.  In  them  it  occurs 
frequently  during  an  attack  of  croup,  or  in  severe  catarrhs  in 
which  the  bronchial  obstruction  is  very  great.  In  these  cases  we 
cannot  attribute  the  accident  to  the  act  of  crying,  since  this  takes 
place  chiefly  during  expiration ;  but  rather  to  the  violent  inspira- 
tions which  they  take  immediately  before  crying,  or  during  fits 
of  anger,  or  in  struggling,  so  common  in  this  stage  of  life.  It 
occurs  also,  but  much  seldomer,  in  adults,  during  the  existence 
of  the  before-mentioned  diseases.  Of  these  the  most  efficient  in 
its  production  is  the  acute  suffocative  catarrh,  particularly  if  of 
some  days'  duration,  and  when  complicated  with  a  slight  perip- 
neumony.  Perhaps  also  we  ought  to  range  among  the  causes 
of  this  affection  a  spontaneous  exhalation  or  secretion  of  air ;  as 
we  find  a  similar  secretion  to  take  place  in  the  cellular  substance 
of  other  organs. 

It  may  appear  surprising  that  the  interlobular  emphysema 
does  not  almost  always  supervene  to  the  vesicular,  particularly 
after  attacks  of  asthma,  the  consequence  of  the  renewal  of  the 
dry  catarrh  in  an  acute  form.  Nevertheless,  although  I  have 
myself  seen  several  cases  of  the  vesicular  species  since  the  publi- 
cation of  my  first  edition,  and  although  I  have  received  from  my 
pupils  many  preparations  of  the  same  lesion  collected  from  the 
different  hospitals  in  Paris,  I  have  never  observed  the  two  spe- 
cies combined,  nor  any  further  extravasation  of  air  than  into  the 


EMPHYSEMA    OF    THE    LUNGS. 


183 


cellular  substance  connecting  the  pleura  with  the  lungs.  This 
is  no  doubt  owing  to  the  air  cells  having  become  thickened 
during  the  continuance  of  the  other  species,  which  is  a  chronic 
disease.  Besides,  Reisseissen  has  remarked  that  the  cellular 
tissue  between  the  lobules  is  extremely  dense,  and  cannot  be 
penetrated,  but  with  great  difficulty,  by  the  process  of  insuffla- 
tion. 

Signs.  There  is  one  sign  completely  pathognomonic  of  this 
affection,  viz.  the  dry  crepitans  rhonchus  with  large  bubbles, 
when  very  distinct  and  continuous,  or  nearly  so.  I  am  not  aware 
that  this  sign  is  ever  wanting  in  this  case,  and  it  is  always  more 
marked  than  in  the  vesicular  emphysema.  Together  with  this 
sign  we  usually  perceive  also,  during  inspiration  and  expiration, 
a  sound  or  sensation  as  of  one  or  more  bodies  rising,  and  falling, 
and  rubbing  against  the  ribs.  These  phenomena  present  con- 
siderable varieties.  They  are  commonly  re-united,  but  occa- 
sionally they  exist  singly,  or  they  alternate.  The  friction  of 
ascent  takes  place  during  inspiration ;  the  dry  crepitous  rhon- 
chus usually  does  the  same,  and  often  masks  the  former  com- 
pletely. The  friction  of  descent  accompanies  expiration,  and  is 
much  more  frequently  to  be  perceived  than  the  other  kind :  it 
sometimes  takes  place  as  one  sound  ;  at  other  times  it  occurs  in 
two  or  three  successive  sounds ;  very  frequently  it  is  only  per- 
ceived immediately  after  expiration,  and  then  conveys  the  im- 
pression as  if  something  were  descending  into  its  proper  place. 
Most,  commonly  the  friction  seems  to  take  place  against  the 
costal  pleura ;  at  other  times  it  appears  to  have  its  site  on  the 
diaphragm,  or  mediastinum,  or  between  the  lobes  of  the  lungs. 
These  phenomena  are  sometimes  accompanied  by  a  crepitation 
perceptible  by  the  hand.  This  sign  is,  however,  frequently 
wanting,  and  usuajly  disappears  before  the  others  ;  but  some- 
times, though  rarely,  it  is  more  perceptible,  at  least  at  intervals, 
than  they  are.  The  dry  crepitous  rhonchus  with  large  bubbles, 
and  the  friction  of  ascent  and  descent,  are  less  liable  to  temporary 
interruption  from  obstruction  of  the  bronchial  tubes,  than  most 
of  the  other  stethoscopic  signs  ;  such  interruption,  however,  some- 
times does  take  place,  and  may  even  last  several  days  in  cases  where 
the  lesion  is  confined  to  a  small  space.  In  some  cases  we  can 
produce  the  crepitation  by  pressing  the  intercostal  spaces  over 
the  affected  part.  The  chest  sounds  well  on  percussion  over  the 
site  of  the  emphysema,  unless  there  happens  to  co-exist  a  gorged 
state  of  the  lungs  from  peripneumony  or  other  cause.  Should 
an  external  emphysema  make  its  appearance  at  the  same  time, 
beginning  in  the  heck,  the  diagnosis  of  course  is  rendered  more 
certain.  In  respect  of  symptoms  of  a  general  or  local  kind '  in- 
dicative of  this  disease,  I  believe  that  a  dyspnoea  coming  on  sud- 


184  EMYHYSEMA    OF    THE    LUNGS. 

denly  after  a  violent  exertion,  or  continuing  in  a  marked  degree 
after  croup,  suffocative  catarrh,  or  any  other  disease  which  may 
have  given  rise  to  temporary  obstruction  of  the  bronchi,  is  the 
only  one  from  which  its  existence  can  be  suspected.  To  this  it 
may  be  added,  that  the  patients  are  sometimes  sensible  of  a  kind 
of  crackling  in  the  part  affected. 

Treatment.  Interlobular  emphysema  is  usually  an  affection 
of  less  severity  than  we  might  be  led  to  expect.  When  the 
aerial  infiltration  extends  to  the  external  parts,  a  few  pricks  with 
the  lancet  at  the  lower  part  of  the  neck,  or  wherever  the  emphy- 
sema is  greatest,  usually  suffice  to  dissipate  it.  When  it  is  con- 
fined to  the  lungs,  the  air  appears  to  be  always  absorbed,  and 
the  interlobular  partitions  gradually  return  to  their  natural  state. 
I  never  met  with  a  fatal  result  from  this  disease  alone ;  and  I 
have  seen  several  recoveries  from  it,  in  cases  where  its  exisitence, 
even  to  a  great  extent,  was  most  satisfactorily  established.  I 
will  here  notice  two  cases  of  the  kind. 

1.  A  young  woman,  convalescent  from  a  severe  acute  catarrh, 
in  the  winter  of  1823-4,  presented  the  most  evident  signs  of  this 
disease,  on  the  right  side  over  a  space  larger  than  the  hand.  The 
dry  crepitous  rhonchus  with  large  bubbles,  and  the  frictiqn  of 
ascent  during  inspiration  and  of  descent  during  expiration,  were 
heard  strongly  and  distinctly.  A  sense  of  crepitation  was  also 
felt  by  the  hand  during  the  stronger  inspirations :  sometimes, 
however,  this  was  altogether  wanting,  and  at  other  times  it  could 
be  excited  by  pressure  in  the  intercostal  spaces.  The  dyspnoea 
which  was  considerable  when  I  first  saw  the  patient,  gradually 
diminished,  and  the  phenomena  above  mentioned  gradually  de- 
creased with  it.  At  the  end  of  two  months  the  young  woman 
left  the  hospital.  I  saw  her  in  the  ensuing  spring,  and  found 
her  quite  well  and  without  any  symptom  of  emphysema. 

2.  A  man  aged  twenty  came  into  the  clinical  wards  the  9th  of 
May,  1825,  affected  with  a  very  severe,  catarrh  of  three  weeks' 
duration.  At  this  time  he  had  all  the  symptoms  of  the  acute 
suffocative  catarrh,  extreme  dyspnoea,  tracheal  rhonchus,  high 
fever.  The  chest,  on  percussion,  sounded  pretty  well  through- 
out, but  perhaps  somewhat  imperfectly  on  the  left  back ;  the 
sound  of  respiration  was  feeble  or  moderate  every  where  ;  mucous, 
sonorous,  and  sibilous  rhonchi,  singly  or  conjoined,  existed  in 
different  points  ;  and  a  slight  crepitous  rhonchus  with  bronchial 
respiration  was  perceived  at  the  roots  of  the  left  lung.  The 
mucous  rhonchus  was  felt  by  the  hand  in  several  places,  particu- 
larly on  the  sides.  There  was  also  a  sub-crepitous  rhonchus  at 
the  root  of  the  right*  lung.  These  latter  signs  being  indicative 
of  an  incipient  double  peripneumony,  although  there  was  as  yet 
hardly  any  expectoration,  I  ordered  eight  ounces  of  blood  to  be 


EMPHYSEMA  OF  THK  LUNGS.  185 

taken  from  the  arm,  and  prescribed  emetic  tartar  in  large  doses. 
(See  the  chapter  on  Pneumonia.)  This  was  borne  moderately 
well,  and  produced  considerable  action  on  the  bowels,  without 
vomiting.  On  the  1 2th,  the  expectoration  was  glutinous  and 
tinged  with  blood,  and  there  was  severe  pain  of  the  right  side, 
in  consequence  of  which  cupping  glasses  were  applied.  But  the 
tracheal  rhonchus  and  dyspnoea  were  somewhat  diminished,  and 
it  was  further  discovered  by  the  stethoscope  that  the  peripneu- 
mony  had  not  advanced  in  these  points  where  the  crepitous 
rhonchus  had  been  found,  while  it  had  retrograded  in  those 
where  the  bronchial  respiration  had  been  perceptible, — this  mark 
of  hepatization  being  now  superseded  by  a  crepitous  rhonchus. 
On  the  14th,  the  tracheal  rhonchus  being  less,  and  the  strength 
improved,  I  added  some  syrup  of  poppy  to  the  antimonial  mix- 
ture, and  allowed  the  patient  more  soup.  After  this  time,  the 
fever,  diarrhoea,  and  dyspnoea  did  not  return  ;  the  respiration 
began  to  be  pretty  distinct  over  the  whole  chest,  and  although 
it  was  accompanied  by  different  kinds  of  rhonchi,  the  crepitous 
was  not  among  them.  On  the  17th,  the  patient  was  quite  con- 
valescent. On  the  20th,  on  examining  the  chest  more  closely, 
I  discovered  the  friction  of  ascent  and  descent  on  both  sides  of 
the  chest,  and  also  the  dry  crepitous  rhonchus  with  large  bubbles 
— the  former  most  marked  on  the  left,  the  latter  on  the  right 
side.  I  made,  in  consequence,  the  following  addition  to  the  diag- 
nostic ticket  —  Emphysema  interlobular  partium  inferiorum 
utriusque  pulmonis.  This  patient  left  the  hospital  on  the  29th, 
the  signs  of  the  emphysema,  although  daily  decreasing,  being 
still  very  well  marked.*  At  the  end  of  three  weeks  he  called 
upon  me,  when  I  found  him  quite  well,  and  without  any  of  the 
stethoscopic  signs  above  mentioned.! 

*  I  doubt  if  these  two  cases  can  be  regarded  as  instances  of  interlobular  em- 
physema ;  being  disposed  rather  to  regard  them  as  examples  of  slight  pleurisy- 
grafted  upon  catarrh,  or  a  peripneumony  unaccompanied  by  effusion,  and  there- 
fore unmarked  by  cegophony.  As  was  remarked  in  a  former  note,  the  sound  of 
friction  is  equally  perceptible  in  pleurisy  as  in  interlobular  emphysema,  indica- 
ting in  either  case,  according  to  M.  Reynaud,  an  unequal  or  roughened  condi- 
tion of  the  pleura.  Perhaps  it  is  even  exclusively  confined  to  the  former  of  these 
affections,  as  the  dry  crepitous  rhonchus  seems  to  be  to  the  second;  the  reunion 
of  the  two  signs  indicating  the  complication  of  the  two  diseases.  This  is,  at 
least,  the  inference  which  I  draw  from  my  own  observations  while  officiating  in 
M.  Lacniiec's  clinic;  as  in  almost  every  case  where  the  sound  of  friction  is 
noted,  the  card  of  the  diagnosis  bears  the  inscription  of  "  pleurisy  and  interlobu- 
lar emphysema."  The  same  conclusion  is  de-ducible,  still  more  certainly,  from 
the  third  case  of  M.  Reynaud,  as  both  the  sounds  were  perceptible  during  life, 
and  the  two  lesions  were  discovered  after  death.  (See  Journ.  Hc%d.  No.  65, 
p.  576-)— -fM.  L.) 

t   Certain  facts  observed  in  the  Bicetre  hospital  by  Dr.  Pillore,and  mentioned 
in  his   thesis,  January,  1834,  seem  to  show  that  a  considerable  interlobular  em 
physema,  occurring  suddenly,  may  occasion  sudden  death.     M.Pillore  speaks 
of  a  man  aged  69,  received  into  the  wards  of  Bicetre  under  a  chronic  disorder 

24 


186  (EDEMA  OF  THE  LUNGS. 


CHAPTER     IV. 


OF    (EDEMA    OF    THE    LUNGS. 


(Edema  of  the  lungs  is  the  infiltration  of  serum  into  the  sub- 
stance of  this  organ,  in  such  a  degree  as  evidently  to  diminish  its 
permeability  to  the  air  in  respiration.  Although  very  common, 
this  disease  is  very  little  known.  None  of  the  authors  who  have 
treated  formally  of  dropsy,  have  mentioned  it,  and  the  expression 
dropsy  of  the  lungs,  which  occasionally  occurs  in  their  writings, 

of  the  brain,  but  otherwise  not  seriously  menaced  with  death.  One  day  he 
suddenly  became  senseless — his  face  became  purple,  and  in  a  few  minutes  he 
expired.  To  account  for  this  sudden  death,  nothing  was  found  except  a  limited 
emphysema  beneath  the  pleura,  about  four  inches  in  length  and  three  in  width, 
occupying  the  posterior  and  lower  portion  of  the  left  lung. 

M.  Pillore  speaks  of  two  other  cases  of  the  kind.  One  of  these  reported  by 
Dr.  Prus,  relates  to  an  old  man  of  70,  who  went  to  bed  well  at  night,  and  the 
next  morning  was  found  dead  in  his  bed.  The  most  minute  examination  of  his 
body  brought  to  light  nothing  but  an  extensive  sub-pleura]  emphysema. 

The  other  case  was  observed  by  M.  Piett  in  the  service  of  M.  Rochoux  :  a 
person  with  simple  pulmonary  catarrh,  lost  his  senses  suddenly,  and  like  the 
individual  just  mentioned,  died  in  a  few  minutes.  The  only  lesion  that  could 
be  discovered  on  inspection,  was  an  extensive  circumscribed  emphysema  beneath 
the  pleura. 

In  eases  like  these,  we  must  allow  the  existence  of  a  spontaneous  rupture  of 
the  pulmonary  tissue.  We  must  allow  too,  that  this  sudden  rupture  may  dis- 
turb the  respiration  to  such  a  degree  as  to  cause  death  as  sudden  as  that  occa- 
sioned by  the  rupture  of  the  heart  or  one  of  the  great  vessels,  or  by  a  profuse 
cerebral  haemorrhage.  The  experiments  made  upon  animals  by  Dr.  Leroyd'  Etiol- 
les  lead  to  the  same  conclusion.  By  inflating  the  bronchi  of  rabbits  so  violently  as 
to  rupture  a  number  of  the  air  cells  of  the  lungs,  this  physician  caused  the 
death  of  these  animals  as  suddenly  as  could  have  been  done  by  dividing  the 
medulla  oblongata. — Andral. 

This  disease  has  been  only  hitherto  known  to  Engligh  practitioners  when 
manifested  by  the  extension  of  the  emphysema  to  the  external  subcutaneous  cel- 
lular substance.  Various  cases  of  this  kind  occurring  during  labor  and  from  se- 
vere coughing,  are  recorded  in  our  miscellaneous  collections.  I  shall  here  re- 
fer to  some  of  the  most  remarkable  of  these  which  took  place  during  labor.  Med. 
Commun.  vol.  i.  p.  176  ;  Med.  Facts,  vol.  ii.  p.  45  ;  Halliday  on  Emphysema,  p. 
46;  Ed.  Journ.  vol.  vii.  p.  174;  Cyclopred.  of  Pract.  Med. "vol.  ii.  p.  16  ;  Dub. 
Trans,  vol.  iii.  p.  112;  Louis,  Mem.de  l'Acad.  de  Chir.  t.  iv. ;  Diet,  des  Sc. 
Med.  t.  xii.  p.  7.  The  literature  of  emphysema  of  the  lungs  is  very  limited  : 
the  following  are  the  principal  works  in  which  it  is  either  formally  or  inciden- 
tally noticed : — 

1807.  Halliday  (And.,  M.  D.)  Obs.  on  Emphvsema.    London,  8vo. 

1815.  Breschet.  Diet,  des  Sc.  Med.  (Art  Emphyseme,)  t.  xii. 

1820.  Cloqiiet  (Jul.)  De  l'lnfluence  des  efforts  sur  les  organes  renfermes  dans  la 

cavite  thoracique.     Paris,  8vo. 
1823.  Murat.     Diet,  de  Med.  (Art^  Emphyseme,)  t.  vii. 

1829.  Piedagnel.     Recherches  sur  l'Eniphvseme  du  Poumon.     Paris,  8vo. 
1831.  Bouillaud.     Diet,  de  Med.  et  de  Chir.  Pr.  (Art.  Emphyseme.)  t.  vii. 
1833.  Townsend.      Cyc.  of  Pract.  Med.     (Art.  Emphysema  and  Emphvsema  of 
the  Lungs.)  vol.  ii.  e  F  Transl 


(EDEMA    OF    THE    LUNGS.  187 

is  generally  applied  to  cases  of  hydrothorax,  or  to  the  supposed 
existence  of  cysts  of  serous  fluids  in  the  lungs,  the  rupture  of 
which  was  considered  as  giving  rise  to  hydrothorax.*  Among 
practical  writers,  Albertinif  and  BarrereJ  are  the  only  ones  who 
have  paid  any  attention  to  this  disease,  and  who  have  given  any 
cases  of  it.  The  observations  of  the  latter,  particularly,  prove 
that  he  was  well  acquainted  with  the  affection,  although  he,  per- 
haps, attached  too  much  importance  to  it,  and  did  not  distinguish 
sufficiently  between  it  and  the  first  stage  of  peripneumony. 

(Edema  of  the  lungs  is  rarely  a  primary  and  idiopathic  dis- 
ease. It  conies  on,  most  commonly,  with  other  dropsical  affec- 
tions, in  cachectic  subjects,  towards  the  fatal  termination  of 
long-continued  fevers,  or  organic  affections,  especially  those  of 
the  heart.  Peripneumony  that  has  terminated  by  resolution, 
appears  also  to  leave  a  great  predisposition  to  it ;  and  the  most 
extensive  and  severe  cases  that  I  have  met  with,  occurred  during 
a  temporary  convalescence  from  severe  attacks  of  this  disease. 
Acute  and  chronic  catarrhs,  likewise,  predispose  to  it ;  and  in 
such  cases  it  often  proves  fatal  by  inducing  suffocation.  Although 
this  disease  is  commonly  a  mere  consequence  of  other  affections, 
and  often  takes  place  only  a  few  hours  before  death,  neverthe- 
less, in  some  cases,  it  has  certainly  lasted  several  weeks,  and  even 
months ;  and,  in  a  few  of  these,  it  seems  to  have  been  idiopathic. 
The  suffocative  orthopnoea,  which  sometimes  carries  off  children 
after  attacks  of  measles,  is  probably  idiopathic  anasarca  of  the 
lungs.  I  have  not  hitherto  been  able  to  verify  this  conjecture 
by  dissection  ;  but  when  we  consider  the  dropsical  tendency  of 
such  cases,  and  the  frequent  complication  of  measles  with  perip- 
neumony, it  would  seem  to  be  well  founded. 

Anatomical  character's.  When  oedema  occupies  the  whole  of 
one  lung,  and  has  been  of  some  duration,  the  pulmonary  tissue 
loses  entirely  the  slight  rose  tint  which  is  natural  to  it,  and  be- 
comes of  a  pale  grey  color ;  it  is  denser  and  heavier  than  in  its 
sound  state,  and  does  not  collapse  on  opening  the  chest.  It  is, 
however,  still  nearly  as  crepitous  as  before.  It  retains  the  im- 
pression of  the  finger  more  tenaciously  than  a  sound  lung.  Its 
vessels  seem  to  contain  less  blood  than  usual,  and  when  cut  into, 
there  flows  from  it  an  abundance  of  serum,  which  is  either  co- 
lorless or  very  slightly  tawny,  transparent,  and  just  perceptibly 
spumous.  The  characters  last  mentioned  would  suffice  to  dis- 
tinguish this  disease  from  the  first  degree  of  peripneumony  (in 
which  the  serum  effused  into  the  inflamed  lung  is  strongly  tinged 

*  Hippoc.  de  Intern.  Affect. — Carol.  Piso,  de  Morb.  a  serosa  Colluvie. — De 
Haen,  Ratio  Med.  torn.  ii.  pars  v.  cap.  iii.  De  Hydrope  Pectoris, 
t  Comment;  de  Bonon.  so.  inst.  torn.  i. 
J  Observat.  Anatom. — Pcrpignan,  1753. 


188  (EDEMA    OF    THE    LUNGS. 

with  blood,  and  very  frothy,)  even  if  the  characteristic  redness  of 
inflammation  did  not  establish  a  very  marked  distinction  between 
the  two  diseases.  However,  it  is  by  no  means  uncommon  to  find, 
in  anasarcous  lungs,  some  spots  inflamed  (as  in  peripneumony) 
in  the  first,  and  even  second  degree, — the  inflammatory  affection 
gradually  shading  into  the  merely  oedematous  condition  of  the 
surrounding  parts.  Facts  of  this  kind  point  to  the  great  affinity 
(which  will  be  noticed  more  particularly  hereafter)  between  in- 
flammation and  the  dropsical  diathesis.  When  the  disease  is  of 
recent  occurrence,  the  serum  is  very  frothy.  That  variety  of  it 
which  occurs  immediately  before  death,  is  usually  partial,  and 
occupies  the  posterior  and  inferior  part  of  the  lungs,  like  the 
mechanical  infiltration  which  occurs  after  death,  and  with  which 
it  may  be  considered  as  almost  identical.  Whatever  may  be  the 
intensity  of  the  oedema,  it  produces  no  change  in  the  integrity  of 
the  alveolar  structure  of  the  organ.  This  fact  is  not,  however, 
quite  obvious  until  we  cut  into  the  diseased  lung,  owing  to  the 
fluid  contained  in  the  cellular  tissue.  When  oedema  of  the.  lungs 
has  been  of  long  standing  and  universal,  we  do  not  commonly 
perceive  the  sanguineous  congestion  of  the  posterior  parts  of  the 
lungs,  as  in  ordinary  cases.  We  must  not  confound  with  the 
true  pulmonary  anasarca  a  species  of  infiltration  which  often 
takes  place  in  phthisis,  in  the  intervals  of  the  tuberculous  masses, 
and  which  I  shall  notice  in  its  place.* 

Symptoms  and  signs.     The  symptoms  of  this  affection  are  ex- 

*  It  would  seem  after  what  has  been  stated,  that,  witli  the  exception  of  a  few 
cases  admitted  by  Laennec  rather  as  possibilities  than  as  having  come  under  his 
observation,  oedema  of  the  lungs  is  an  affection  essentially  chronic,  stealthy 
in  its  attack,  and  slow  in  progress.  No  doubt  this  is  commonly  the  fact ;  but 
sometimes  the  contrary  may  be  observed  :  this  disorder  may  appear  suddenly, 
and  attain  to  such  a  degree  of  intensity  in  a  very  short  time  as  to  cause  death  in 
the  midst  of  a  suffocation,  which  maybe  compared  to  that  occasioned  by  oedema 
of  the  glottis. 

In  consequence  o£  the  diversity  of  the  symptoms  occasioned  by  oedema  of 
the  lungs  during  its  development)  I  have  been  accustomed  in  my  lectures,  to 
distinguish  three  forms  of  this  disease  : — 

In  the  first  form,  which  is  the  most  acute,  a  sudden  and  extreme  dyspnoea 
is  experienced,  which  causes  death  often  in  a  very  short  time. 

In  the  second  form,  less  acute  than  the  first,  the  dyspnoea  is  less,  although 
quite  severe.  Like  the  first,  its  attack  is  sudden,  and  death  ensues  in  a  few 
days. 

The  third  form  constitutes  a  true  chronic  malady  :  the  dyspnoea  is  slight, 
especially  during  a  state  of  repose,  and  a  favorable  termination  may  take  place 
sooner  or  later. 

(Edema  of  the  lungs,  whichever  of  its  forms  it  may  assume,  appears  to  me 
to  have  its  seat  in  the  cellular  tissue  which  separates  the  air  vesicles  from  each 
other.  Like  all  cases  of  hyperemia,  it  may  be  active,  passive  or  mechanical; 
It  is  active  particularly  when  it  takes  the  first  of  the  three  forms  above  described. 
It  is  passive  in  many  cases  where  it  comes  on  towards  the  termination  of  chronic 
diseases,  the  fatal  termination  of  which  it  hastens  ;  in-  when  it  invades  the  tissue 
of  lungs  which  have  been  affected  a  number  of  times  with  acute  inflammation. 
An  example  of  the  mechanical  form  of  the  disease  may  often  be  seen  in  an 
individual  laboring  under  an  organic  affection  of  the  heart.— Andral. 


(EDEMA  OF  THE  LUNGS.  189 

tremely  equivocal.  Impeded  respiration,  slight  cough  with 
more  or  less  of  a  watery  expectoration,  are  the  only  signs  by 
which  we  can  be  led  to  suspect  its  existence.  In  some  cases  there 
is  scarcely  any  perceptible  expectoration  :  in  others  it  is  copious, 
colorless,  frothy,  and  of  a  consistence  and  appearance  resembling 
white  of  egg  dissolved  in  equal  parts  of  water.  Like  the  expecto- 
ration of  peripneumony,  it  adheres  to  the  bottom  of  the  vessel 
containing  it,  when  this  is  reversed,  but  it  is  much  more  liquid  and 
less  tenacious.  In  cases  where  the  oedema  is  complicated  with 
partial  spots  of  pulmonic  inflammation,  amid  the  mass  of  expecto- 
ration just  described  there  are  found  some  sputa  of  a  tawny,  green- 
ish or  light  rusty  color,  but  still  less  transparent.  This  sort  of  ex- 
pectoration resembles  that  of  the  pituitous  catarrh. 

Percussion  hardly  affords  any  useful  result  in  oedema  of  the 
lungs.  Both  lungs  are  either  equally  affected  at  the  same  time, 
or  if  one  is  more  so  than  the  other,  there  appears  to  be  still  a 
sufficient  quantity  of  air  retained  in  it  to  prevent  its  yielding  the 
dull  sound.  The  stethoscope  furnishes  two  means  of  diagnosis 
in  this  case.  The  respiration  is  much  feebler  than  might  be  ex- 
pected, from  the  great  dilatation  of  the  thorax;  and  there  is,  at 
the  same  time,  a  slight  Crepitation,  as  in  the  first  degree  of  perip- 
neumony, more  like  a  rhonchus  than  the  natural  sound  of  respi- 
ration. This  crepitous,  or  rather  subcrepitous  rhonchus,  is  more 
humid  than  in  peripneumony,  and  the  bubbles  appear  larger.  It 
must  be  admitted,  however,  that  it  is  sometimes  difficult  to  dis- 
tinguish these  two  diseases  by  the  stethoscope  alone,  without 
taking  into  account  the  general  symptoms.  When  the  oedema  is 
very  general  and  in  a  high  degree,  the  natural  sonorousness  of 
the  chest  is  very  perceptibly  lessened  ;  and  in  these  cases  there 
is  slight  bronchophony,  particularly  at  the  roots  of  the  lungs. 
But  we  can  almost  always  distinguish  the  oedema  from  the  inci- 
pient peripneumony,  by  the  long  continuance  of  the  crepitous 
rhonchus  and  the  absence  of  the  general  symptoms  of  inflam- 
mation in  the  former  disease. 

There  is  another  case  in  which  the  signs  of  oedema  are  ex- 
tremely obscure  or  altogether  wanting,  that,  namely,  where  it 
supervenes  to  emphysema  or  the  severer  dry  catarrh.  If  we  have 
previously  ascertained  the  existence  of  the  catarrh  or  emphysema, 
we  shall  scarcely  be  aware  of  the  addition  of  the  oedema,  the 
respiration  being  too,  feeble  to  permit  the  development  of  the 
crepitous  rhonchus  ;  and  if  the  case  is  first  presented  to  us  in  its 
state  of  complication,  the  nearly  total  absence  of  the  respiratory 
sound,  the  sonorousness  of  the  chest,  and  the  slight  sibilous 
rhonchus,  will  only  point  out  to  us  the  emphysema.* 

*  In  this  case,  the  best  method  to  produce  the  crepitous  rhonchus  is  to  make 
the  patient  cough  or  hold  his  breath  for  a  considerable  time.—  Author. 


190  (EDEMA    OF    THE    LUNGS. 

Should  the  patient  die,  the  examination  of  the  body  is  likely 
to  lead  us  into  an  error  on  the  other  side  :  we  shall  at  first  per- 
ceive only  the  oedema ;  and,  indeed,  if  this  is  considerable,  some 
attention  will  be  necessary  to  enable  us  to  find  any  signs  of  the 
emphysema.  The  air-cells  when  charged  with  serum  lose  their 
transparency,  the  lungs  do  not  collapse,  nor  are  the  dilated  cells 
more  prominent  than  the  others.  It  is  here  to  be  observed, 
however,  that  it  is  very  rare  for  the  whole  lungs  to  be  so  very 
oedematous,  as  not  to  leave  some  points,  particularly  at  the  ante- 
rior edge  and  ends  of  the  lobes,  in  a  state  to  exhibit  the  emphyse- 
ma. When  there  is  any  doubt  as  to  the  state  of  the  parts,  we  must, 
inflate  the  suspected  portions,  include  them  within  a  ligature,  and 
then  dry  them  ;  the  dilated  cells  will  become  more  apparent  as 
the  surface  loses  its  humidity.  The  same  remarks  apply  still 
more  forcibly  to  peripneumony,  as  masking,  in  the  dead  body, 
the  characters  of  emphysema.  In  the  case  of  this  complication, 
moreover,  it  will  be  often  a  matter  of  difficulty  to  recognize  the 
peripneumony  in  the  living  subject,  if  the  disease  is  not  so  far 
advanced  as  to  produce  a  dull  sound  on  percussion,  which  will 
only  be  the  case  in  the  second  and  third  stages  of  the  inflamma- 
tion. If,  indeed,  we  have  ascertained  tfre  existence  of  the  em- 
physema previously,  percussion  will  enable  us  to  detect  the 
peripneumonic  affection,  as  the  sound  will  become  entirely  dull 
as  soon  as  the  disease  has  made  considerable  progress. 

I  have  thought  it  necessary  to  enter  into  these  details,  on  ac- 
count of  the  occasional  difficulty  of  recognizing  these  diseases, 
both  in  the  living  and  dead  subject,  when  they  are  combined  ; 
and  because  an  inattentive  observer,  after  being  mistaken  in  cases 
of  this  kind,  might  be  led  to  conclude  that  the  signs  of  inflam- 
mation, emphysema,  and  oedema  of  the  lungs,  laid  down  in  this 
work,  are  neither  certain  nor  constant.  The  following  case 
affords  an  example  of  the  facility  with  which  such  a  mistake 
might  be  made  by  a  practitioner  ignorant  of  the  characters  of 
emphysema,  both  in  the  living  and  dead  body. 

Case  IX.  A  man,  sixty  years  of  age,  came  into  the  Neckcr 
Hospital,  with  every  symptom  of  the  most  marked  emphysema. 
The  chest  sounded  well,  and  the  respiration  was  perceptible  only 
in  a  very  slight  degree  and  at  intervals,  in  different  points,  which 
were  variable  :  it  was  also  attended  by  a  slight  rhonchus  like  the 
clicking  of  a  valve.  Having  ascertained  the  nature  of  the  disease, 
and  the  patient  being  in  a  hopeless  state,  I  did  not  again  percuss 
the  chest ;  but  I  ascertained  by  the  stethoscope  that  respiration 
was  entirely  wanting  in  the  upper  part  of  the  right  side,  during 
the  three  last  days  of  his  life.  Upon  examining  the  body,  the 
superior  lobes  of  the  right  lung  were  found  inflamed,  being  very 
red,  nearly  as  hard  as  liver,  and   without  any  trace  of  the  air 


(EDEMA  OF  THE  LUNGS.  191 

cells :  the  rest  of  this  lung  was  loaded  with  serum,  which  was 
slightly  bloody  in  some  points,  and  quite  colorless  in  others. 
The  left  lung  was  not  at  all  inflamed,  but  was  also  loaded  with 
serum,  although  in  a  less  degree  than  the  other.  The  serum  was 
also  more  frothy,  and  more  generally  colorless.  At  first  sight 
neither  of  the  lungs  seemed  to  be  emphysematous,  except  that 
there  was,  on  the  surface  of  the  upper  left  lobe,  one  air-cell  enor- 
mously dilated,  very  like  a  grape-stone.  Upon  cutting  into  this, 
there  was  found  a  cavity  within  the  pulmonary  substance,  capable 
of  containing  a  filbert,  and  whose  walls  were  formed  by  air-cells 
which  seemed  to  open  into  it.  Upon  examining  attentively  the 
surface  of  both  lungs,  a  great  number  of  cells,  here  and  there, 
were  found  dilated  sufficiently  to  contain  a  millet  or  hemp-seed, 
although  their  dilatation  did  not  strike  the  eye  at  first,  on  ac- 
count of  the  loss  of  transparency  from  the  oedema.  There  were 
also  three  or  four  protuberances,  corresponding  to  ruptures  of  the 
pulmonary  tissue,  like  those  described  in  the  preceding  chapter. 

This  patient  exhibited  the  signs  of  pulmonary  emphysema  in 
so  striking  a  degree,  that  it  could  not  have  been  mistaken  even 
by  the  least  informed  student,  after  reading  the  account  I  have 
given  of  this  affection:  and  yet  it  is  almost  certain  that,  upon 
examining  the  body  after  death,  such  a  person  would  have  re- 
cognized no  other  mark  of  it  besides  the  greatly  dilated  and 
prominent  cell  above  mentioned,  and  would,  therefore,  have  con- 
cluded either  that  Tie  was  mistaken  in  his  diagnosis,  or  that  the 
signs  of  emphysema  are  uncertain. 

I  shall  now  detail  three  more  cases  of  oedema  of  the  lungs — 
the  first  exhibiting  the  disease  in  a  state  of  simplicity  ;  the  second 
being  an  example  of  the  complication  just  noticed ;  and  the  third 
an  instance  of  this  affection  supervening  to  a  severe  peripneu- 
mony,  and  before  the  resolution  of  the  inflammation  had  been 
fully  established. 

Case  X. — (Edema  of  the  lungs,  with  ascites  and  anasarca. 
A  woman  aged  forty-seven,  subject  to  irregular  menstruation  for 
a  twelvemonth,  was  suddenly  seized  with  a  severe  pain  in  the  left 
side,  attended  by  dyspnoea  and  cough.  She  came  into  the  hos- 
pital a  fortnight  thereafter,  affected  with  oedema  of  the  superior 
extremities,  particularly  the  left — dyspnoea  and  cough,  (not  very 
frequent,)  with  expectoration  of  white  viscid  sputa,  intermixed 
with  much  saliva.  These  symptoms  got  better  during  the  first 
month ;  but  during  the  second,  the  anasarca  greatly  increased, 
and  extended  over  the  whole  body,  except  the  face.  She  had 
sometimes  pain  in  the  chest,  and  sometimes  in  the  abdomen. 
The  pulsation  of  the  heart  was  irregular,  and  the  pulse  very  in- 
distinct. The  patient  took  little  sleep,  coughed  a  little,  and  ex- 
pectorated blackish  sputa.     During  all  this  time  the  respiration 


192  (EDEMA  OF  THE  LUNGS. 

was  pretty  distinctly  audible  throughout  the  chest,  but  accom- 
panied by  a  slight  crepitous  rhonchus.  At  this  time  the  diag- 
nosis was  given — oedema  of  the  lungs  ivith  general  serous  diathe- 
sis. A  fortnight  after  this,  and  a  month  before  her  death,  it  was 
found,  on  applying  the  stethoscope,  that  the  respiration  was  very 
distinct  on  both  sides  anteriorly,  and  was  accompanied  by  a  slight 
crepitous  rhonchus  on  the  lower  parts  of  the  sides  and  back. 
She  died  about  three  months  after  her  admission. 

Dissection  thirty  hours  after  death. — The  cavities  of  the 
pleura  contained  somewhat  less  than  a  pint  of  limpid  serum  ;  the 
lungs  adhered  nearly  through  their  whole  extent  by  long  cellular 
attachments,  and  their  substance  was  throughout  little  crepitous, 
and  injected  by  a  frothy  and  nearly  colorless  serum,  which  gave 
the  lungs  a  sort  of  semi-transparency,  and  flowed  copiously  from 
them  when  cut  into.  In  other  respects  the  pulmonary  tissue  was 
sound,  of  a  pale  rose-color,  free  from  tubercles,  and  exhibiting 
no  trace  of  peripneumony,  nor  even  of  sanguineous  congestion. 
There  was  found  water  in  the  cavities  of  the  pericardium  and 
peritoneum. 

Case  XI. — QZdema  supervening  to  emphysema  of  the  lungs. 
A  woman,  aged  forty-five,  who  had  been  affected  (according  to 
her  own  account)  with  asthma  and  habitual  cough,  attended  by 
a  slight  expectoration,  ever  since  she  was  nine  years  old,  came 
into  the  Necker  Hospital  in  March  1819,  on  account  of  an  ag- 
gravation of  her  dyspnoea  and  a  local  pain  or  the  leg.  At  this 
time  the  respiration  was  short,  difficult,  and  interrupted  by  fits 
of  coughing,  followed  by  yellow  mucous  expectoration ;  the  skin 
was  rather  cold,  the.  action  of  the  heart  regular,  and  the  pulse  a 
little  'frequent.  The  sound  of  respiration  was  very  indistinct  over 
the  whole  chest,  and  was,  now  and  then,  accompanied  by  a  slight 
rhonchus,  which  was  at  one  time  sibilous,  and  at  another  like  the 
clicking  of  a  valve.  The  chest  sounded  somewhat  imperfectly 
on  the  left  back.  From  these  indications  the  diagnosis  was 
given — Chronic  catarrh — Emphysema  of  the  lungs.  During  the 
succeeding  month  the  oedema  of  the  lower  extremities,  which-  was 
very  slight  on  her  entrance,  increased ;  and  she  had  comatose 
symptoms,  which  seemed  to  threaten  apoplexy.  These  continued 
more  or  less  ;  the  anasarca  became  general,  and,  together  with  a 
severe  attack  of  diarrhoea,  exhausted  the  patient,  who  died  about 
six  weeks  after  her  entry. 

Dissection  twenty-four  hours  after  death. — There  was  a  good 
deal  of  water  in  the  head.  The  right  lung  exactly  filled  the 
cavity  of  the  chest,  and  remained  uncollapsed ;  it  adhered 
throughout  to  the  pleura  by  well  organized  cellular  lamina;, 
which  were  in  some  places  infiltrated  with  a  yellowish  serosity. 
On  the  anterior  surface  of  the  lung  several  of  the  air-cells  were 


(EDEMA    OF    THE    LUNGS. 


193 


dilated  to  the  size  of  a  hemp-seed.  The  lung  seemed  pretty 
firm  ;  on  compression  it  was  found  to  retain  the  impression  of 
thV  finger,  and,  when  cut  into,  allowed  a  large  quantity  of  a  clear 
and  slightly  frothy  serum  to  escape.  In  the  upper  part  of  it  there 
were,  hero  and  there,  some  points  of  small  extent,  which  were 
somewhat  red,  compact,  and  not  alveolar,  and  which  exhibited  a 
granulated  surface  when  incised.  The  remainder  of  the  viscus 
had  the  natural  aspect,  and  was  still  sufficiently  crepitous,  but 
heavy ;  it  did  not  yield,  like  the  sound  organ,  to  pressure,  being 
injected  throughout  with  a  large  quantity  of  an  almost  colorless 
serum,  which  could  be  squeezed  from  it  like  water  from  a  sponge. 
The  left  lung  adhered,  in  like  manner,  to  the  pleura,  and  with 
the  exception  of  the  peripneumonic  appearances,  exhibited  the 
same  morbid  condition  as  the  right.  There  was,  further,  on  the 
superior  part,  a  patch  of  fibro-cartilaginous  membrane,  two  or 
three  lines  thick,  which,  in  this  place,  formed  the  medium  of  ad- 
hesion between  the  lungs  and  pleura  of  the  ribs,  to  both  of  which 
it  was  intimately  united.  In  the  interior  of  this  lobe  there  was 
a  vast  tuberculous  excavation,  capable  of  containing  a  middle- 
sized  apple,  (reinette,)  and  which  contained  merely  a  small  quan- 
tity of  a  very  limpid  mucosity.  It  was  lined  throughout  with  a 
polished  diaphanous  membrane,  of  a  consistence  between  that  of 
the  mucous  membrane  and  cartilage.  This  cavity  was  traversed, 
in  different  directions,  by  very  white,  small  rounded  columns, 
which  proved,  on  close  examination,  to  be  obliterated  blood- 
vessels, and  which,  although  continuous  with  the  lining  mem- 
brane of  the  excavation,  were  sufficiently  distinguished  from  it 
by  their  shining  whiteness  and  capacity.  The  trunks  of  these 
obliterated  vessels  terminated  in  culs-de-sac,  either  a  few  lines 
within  or  without  the  excavation.  In  the  obliterated  portions 
the  original  cavity  of  the  vessel  was  still  distinguishable  by  a 
longitudinal  band  of  greater  transparency.  Five  or  six  bronchial 
tubes  opened  into  this  cavity,  in  the  manner  which  will  be  de- 
scribed in  the  chapter  on  phthisis.*  The  pulmonary  tissue  in 
the  inferior  part  of  this  excavation  was  crepitous,  though  injected 
with  serum  ;  in  every  other  part  of  the  boundaries  of  the  cavity, 
it  formed  a  layer,  two  or  three  lines  in  thickness,  which  was 
flaccid,  and  of  a  very  deep  black  color,  owing  to  the  accumula- 
tion of  black  pulmonary  matter.  There  were  no  tubercles  in 
either  lung.  There  was  some  water  in  the  pericardium  and 
peritoneum. 

Case  XII. — QZdema  of  the  lungs  supervening  during  conva- 
lescence from  peripneumony.     A  woman,  aged  forty,  had  been 

*  From  the  patient's  history  it  would  seem  that  this  vast  pulmonary  fistula 
had  existed  ever  since  her  ninth  year.  The  case  is  further  remarkable  from  the 
circumstance  of  the  excavation  being  traversed  by  blood-vessels. — Author. 

25 


194  (EDEMA  OF  THE  LUNGS. 

always  from  her  childhood  of  delicate  health,  and  habitually  sub- 
ject to  great  difficulty  of  breathing  and  palpitation  of  the  heart. 
This  state  was  aggravated,  in  her  twenty-seventh  year,  by  the 
supervention  of  general  dropsy,  of  which,  however,  she  was  cured 
by  diuretics:  from  this  time  her  health  continued  still<o  decline. 
Tn  the  beginning  of  January,  1817,  after  having  sat  up  with  a 
sick  person  for  several  nights,  her  respiration  became  extremely 
difficult,  especially  on  motion  ;  she  lost  her  sleep  and  appetite, 
and  she  had  a  slight  cough,  with  mucous  expectoration.  In  this 
state  she  came  into  the  Necker  Hospital  on  the  7th  of  March  fol- 
lowing, with  oedema  of  the  lower  lungs,  livid  lips,  extreme  op- 
pression, frequent  palpitation,  and  startings  during  sleep.  At 
this  time  the  chest  on  percussion  yielded  an  imperfect  sound  on 
the  left  side  before,  and  the  right  side  behind,  and  no  sound  at 
all  in  the  region  of  the  heart ;  and  in  all  these  points  the  stetho- 
scope detected  no  respiratory  murmur".  The  heart  yielded  a 
distinct  sound,  but  scarcely  any  impulse,  when  explored  by  the 
stethoscope.  From  these  premises  the  diagnosis  was  given — 
Partial  peripneumony  of  both  lungs — dilatation  of  the  heart 
without  hypertrophy.     She  died  on  the  2nd  of  June. 

Dissection  twenty-four  hours  after  death.  The  brain  was 
natural,  but  with  a  small  quantity  of  serum  in  the  ventricles. 
There  was  about  half  a  pint  of  serum  in  each  side  of  the  chest, 
and  some  cellular  adhesions  on  the  right.  The  upper  part  of 
the  right  lung  was  sound,  only  injected  with  a  colorless  serum. 
The  middle  and  inferior  lobes  were  more  compact,  and  dis- 
charged, when  cut  into,  a  great  quantity  of  transparent  colorless 
serum,  intermixed  with  a  thicker,  yellowish,  puriform  fluid. 
These  lobes  were,  nevertheless,  crepitous,  with  the  exception  of 
a  few  spots,  of  small  extent,  here  and  there,  which  had  a  density 
almost  equal  to  that  of  liver,  a  yellow  and  somewhat  reddish 
color,  and  a  granulated  surface  on  incision.  The  left  lung  was 
in  the  same  state,  only  without  the  more  solid  portions.  Both 
lungs  had  a  yellowish  grey  color,  like  that  of  this  viscus  when 
infiltrated  with  pus  after  an  attack  of  peripneumony,  only  paler. 
Indeed,  it  appeared  evident  that,  in  this  case,  a  peripneumony  of 
the  inferior  portion  of  both  lungs  had  ended  in  suppuration,  and 
that  the  greater  part  of  the  pus  had  been  absorbed,  the  final 
restoration  of  the  part  failing  through  the  debility  of  the  system. 
The  pericardium  contained  two  ounces  of  serum.  The  heart 
was  large,  its  substance  soft  and  easily  torn,  and  its  cavities  very 
voluminous.* 

*  This  chapter  is  purely  anatomical ;  and  it  is  probable  that  all  notice  of 
treatment  was  purposely  omitted  by  the  author.  (Edema  of  the  lungs  is  in  fact 
bo  generally  symptomatic,  that  its  treatment  must  merge  in  that  of  the  accom- 
panying aftection,     1  will,  however,  subjoin  some  directions  on   this  point,  ex- 


PULMONARY  APOPLEXJT.  195 


CHAPTER  V. 


OF    PULMONARY    APOPLEXY. 

The  disease  which  I  designate  by  the  name  of  Pulmonary  Apo- 
plexy, though 'very  frequent,  is  yet  very  little  known  in  respect 
of  its  anatomical  characters.  It  is,  however,  well  known  by  its 
principal  symptom,  viz.  haemoptysis,  or  haemorrhage  from  the 
lungs,  usually  severe  and  abundant.  We  have  already  shown 
that  the  slighter  cases  of  haemoptysis  depend  upon  a  simple  ex- 
halation from  the  mucous  membrane  of  the  bronchi.  Those 
cases,  however,  of  violent  and  extreme  haemorrhage,  which  often 
resist  all  medical  treatment,  arise  from  a  very  different  and  more 
dangerous  cause. 

traded  from  M.  Laennec's  notes  for  his  course  of  Lectures  on  Medicine  at  the 
College  ill  France.  When  the  oedema  of  the  lungs  is  active  or  subptripneumonic, 
we  must  treat  it  as  we  do  pneumonia,  with  the  exception  of  bloodletting,  which 
is  contra-indicated  by  the  serous  diathesis.*  Tartar  emetic  in  large  doses,  and 
its  substitutes  the  white  oxyd  of  antimony  and  kermes  mineral,  may  how- 
ever, be  very  useful.  (Vide  the  Chapter  on  Pneumonia.)  When,  on  the 
other  hand,  the  oedema  has  passed  to  the  chronic  stage,  or  when  it  has  put  on 
the  passive  character  from  the  commencement,  we  must  have  recourse  to  the 
ordinary  remedies  for  dropsy,  viz.  purgatives  and  diuretics,  and,  according  to 
the  case,  tonics  and  steel.  The  preparations  of  squill,  nitre  in  large  doses,  and 
the  acetate  of  potass,  are  the  diuretics  most  commonly  employed.  The  latter 
medicine  in  particular  is  very  valuable,  if  given  in  a  sufficiently  large  dose, 
(from  half  an  ounce  to  an  ounce  in  each  pint  of  tissue,)  as  it  then  operates  both 
as  diuretic  and  purgative.  When  the  oedema  is  conjoined  with  disease  of  the 
heart,  its  treatment  merges  entirely  in  that  of  the  latter  affection,  only  that  the 
great  danger  of  the  complication  renders  the  use  of  purgatives  more  applicable 
than  ever,  that  is  to  say,  in  as  far  as  the  strength  will  permit  their  administra- 
tion. Blisters  are  rarely  beneficial  in  oedema  of  the  lungs  ;  and  they  are  par- 
ticularly contra-indicated  in  the  case  of  complication  with  disease  of  the  heart. 
—(M.  L.) 

*  This  treatment  is  not  contra-indicated  in  all  cases  of  serous  effusions.  Ex- 
perience has  shown,  in  fact,  that  in  many  cases,  one  or  more  bleedings  practised 
in  season,  evidently  favors  the  absorption  of  the  effused  fluid,  as  for  instance, 
in  cases  belonging  to  the  class  of  active  hyperemias. 

Among  the  cases  of  dropsy,  which  take  place  mechanically  as  it  were,  under 
the  influence  of  the  congestion  of  the  liver,  or  in  consequence  of  hypertrophy 
of  the  heart,  there  are  some  which  bleeding  assists  to  remedy,  because  it  dimin- 
ishes the  obstruction  encountered  by  the  blood  in  its  passage  through  the  liver 
or  the  heart. — Andral. 

(Edema  of  the  lungs  is  noticed  by  many  English  authors.  Dr.  Bailie,  how- 
ever, says,  he  has  not  seen  any  well-marked  example  of  it.  Morb.  Anat.page 
77.  Dr.  Parry  considers  it  (Elements,  page  106)  as  a  frequent,  and  indeed  neces- 
sary,  consequence  of  peripneumony  ;  and  in  this  he  seems  corroborated  by  the 
experience  of  our  author.  Dr.  Darwin  notices  it  among  other  dropsies,  under 
the  title  Anasarca  Pulmonum.  See  Zoonom.  vol.  iii.  p.  172,  London,  1801. 
See  also  Dr.  Percival's  Essays  Med.  and  Exper.  vol.  ii.  p.  173,  et  seq.  This 
author  recommends,  after  the  failure  of  other  means,  paracentesis  of  the  lungs, 
(p.  179,  180,)  with  as  much  earnestness  and  reason  as  Floyer  recommends  the 
same  operation  for  the  cure  of  emphysema  of  the  lungs! — Transl. 


196  PULMONARY    APOPLEXY. 

Anatomical  characters.  This  alteration  consists  in  an  indu- 
ration of  the  lung  equal  to  the  completcst  hepatization.  The 
induration,  however,  is  very  different  from  the  inflammatory 
affection  of  the  lungs  distinguished  by  that  term.  It  is  always 
partial,  and  scarcely  ever  occupies  a  considerable  portion  of  the 
lungs  ;  its  more  ordinary  extent  being  from  one  to  four  cubic 
inches.  It  is  almost  always  very  exactly  circumscribed,  the  in- 
duration being  as  considerable  at  the  very  point  of  termination 
as  in  the  centre.  The  pulmonary  tissue  around  is  quite  sound 
and  crepitous,  and  has  no  appearance  whatever  of  that  progres- 
sive induration  found  in  the  peripneumonic  affection.  The  sub- 
stance of  the  lung  is,  indeed,  often  very  pale  around  the  hscmop- 
tysical  induration ;  sometimes,  however,  it  is  rose-colored,  or 
even  red,  as  if  tinged  with  fresh  blood  ;  but,  even  in  this  case, 
the  circumscription  of  the  indurated  part  is  equally  distinct. 
The  indurated  portion  is  of  a  very  dark  red,  exactly  like  that  of 
a  clot  of  venous  blood.  When  cut  into,  the  surface  of  the  in- 
cisions is  granulated  as  in  a  hepatized  lung  ;  but  in  their  other 
characters,  these  two  kinds  of  pulmonic  induration  are  entirely 
different.  In  the  second  degree  of  hepatization,  along  with  the 
red  color  of  the  inflamed  pulmonary  tissue  we  can  perceive  dis- 
tinctly the  dark  pulmonary  spots,  the  blood-vessels,  and  the  fine 
cellular  intersections ;  all  of  which,  together,  give  to  this  morbid 
state  the  aspect  of  certain  kinds  of  granite.  In  the  induration  of 
haemoptysis,  on  the  contrary,  the  diseased  part  appears  quite  ho- 
mogeneous, being  altogether  black,  or  of  a  very  deep  brown,  and 
disclosing  nothing  of  the  natural  texture  of  the  part,  except  the 
bronchial  tubes  and  the  larger  blood-vessels.  The  latter  have 
even  lost  their  natural  color,  and  are  stained  with  blood.  The 
veins  of  the  affected  part,  and  also  those  adjoining,  are  sometimes 
filled  with  a  firmly  coagulated  and  half-dry  blood,  a  kind  of 
infarctus  which  will  be  noticed  afterwards  when  we  come  to 
treat  of  the  diseases  of  the  pulmonary  vessels.  In  scraping  the 
incised  surfaces  of  these  parts,  we  can  detach  a  small  portion  of 
very  dark,  half-congealed  blood,  but  in  a  much  less  proportion 
than  we  can  press  out  the  bloody  serum  from  a  hepatized  lung. 
The  granulations  on  the  incised  surfaces  have  also  appeared  to 
me  larger  than  in  cases  of  hepatization.  Sometimes  the  centre 
of  these  indurated  masses  is  soft,  and  filled  with  a  clot  of  pure 
blood. 

This  lesion  is  evidently  produced  by  an  effusion  of  blood  into 
the  parenchyma  of  the  lungs,  in  other  words,  into  the  air  cells. 
From  its  exact  resemblance  to  the  effusion  that  takes  place  in  the 
brain  in  apoplexy,  I  have  thought  the  name  Pulmonary  Apojdc.ii/ 


PULMONARY    APOPLEXY. 


197 


very  applicable  to  it,  as  it  resembles  in  every  respect  the  cerebral 
haemorrhage  commonly  termed  apoplexy.* 

The  lungs  and  brain  are  not  the  only  organs  in  which  a  similar 
effusion  may  take  place.  I  have  seen  such  happen  instantane- 
ously in  the  subcutaneous  cellular  substance,  and  I  have  met 
with  them,  during  dissection,  in  almost  every  part  of  the  body, — 
between  the  intestinal  tunics,  among  the  muscular  fibres  of  the 
heart,  and  under  the  cellular  coverings  of  the  pancreas  and  kid- 
neys. In  a  case  of  fatal  apoplexy  I  have  found  large  effusions 
of  blood  in  the  cellular  membrane  of  every  limb,  of  the  trunk, 
and  in  that  surrounding  most  of  the  abdominal  viscera.f  Some 
examples  have  occurred  of  sudden  death  from  haemoptysis, 
wherein  the  substance  of  the  lungs  was  found  lacerated,  and  con- 
taining clots  of  blood.  Corvisart  mentions  one  extraordinary 
case  of  this  kind,  in  which  the  extravasation  had  lacerated  the  lung 
and  filled  the  cavity  of  the  pleura.J  The  haemoptysical  engorge- 
ment above  described,  is  only  a  lesser  degree  of  the  same  affec- 
tion, in  which  the  effused  blood  (still  in  some  degree  under  the 
influence  of  vital   action)  coagulates  in  the    air  cells,  in  such  a 

*  The  perfect  analogy  between  pulmonary  and  cerebral  apoplexy  has  been 
completely  established  in  a  very  admirable  thesis  by  M.  Rousset,  (Recherches 
sur  lis  Hemorrhagies",  Paris,  1827,)  and  in  the  recent  treatise  on  apoplexy,  by 
Professor  Cruveilhier  (Diet,  de  Med.  Prat.  t.  iii.  p.  278.)  We  may  observe  in 
the  lungs,  as  in  the  brain,  and  indeed  in  most  of  the  other  organs,  the  three 
forms  of  hemorrhage,  viz. — 1 .  The  blood-stroke,  (coup-de-sang,)  an  instantaneous 
and  universal  congestion  without  anv  escape  of  blood  from  the  vessels;  of  this 
form  the  lungs  offer  an  example  in  the  case  of  asphyxia,  in  which  the  pulmonary 
fissue,  without  losing  its  wonted  crepitation  on  being  handled,  is  colored  of  a 
dark  red  hue,  and  pours  out,  when  incised,  a  profusion  of  fluid  black  blood  : 
2.  Jlpoplexy,  properly  so  called,  such  as  is  described  in  the  text,  and  varying 
from  simple  infiltration  to  the  largest  coagula  of  blood*,  with  rupture  of  the 
vessels  and  laceration  of  the  organ ;  3.  Slow  hemorrhagic  infiltration  or  spleni- 
sation,  in  which  the  tissue  of  one  whole  lung  or  one  lobe  slowly  and  progres- 
sively penetrated  by  blood,  assumes  a  darkish  red  color,  and  becomes  smooth, 
heavy,  homogeneous,  and  friable  as  the  spleen,  with  the  organization  of  which 
it  presents  a  resemblance  more  or  less  close.  This  last  variety  of  pulmonary 
apoplexy  is  common  in  old  persons  who  have  been  long  confined  to  bed  in  one 
posture.  It  is  also  observed  after  diseases  of  an  adynamic  kind,  whether  acute 
or  chronic.  The  splenised  portions  are  sometimes  softened  partially  or  totally, 
bring  coin  cited  into  a  sort  of  blackish  paste,  which  we  might  mistake  for  the 
effeel  of  putrefaction!  In  some  cases  these  portions  are  intermixed  with  spots 
of  the  inflammatory  hepatization,  recognised  by  their  red  or  yellowish  color, 
and  which  contrast  well  with  the  dark  ground  of  the  general  mass. — (M.  L.) 

1  Effusions  of  blood  may  also  occur  in  the  liver.  In  a  man  who  was  found 
dead  in  his  bed,  I  found,  on  dissection  of  his  body,  the  peritoneum  filled  with 
clots  of  blood,  particularly  about  the  liver:  and  on  examining  this  last  named 
organ  a  rent  was  found  leading  to  a  large  vessel  which  was  ruptured.  This 
lesion  was  the  source  of  the  hemorrhage  and  the  cause  of  his  death. — Jlndral. 

I  Nouvelie  Methode,  fyc.  par  Avenbrugger  traduit  par  Corvisart.  p.  227.  A 
few  other  cases  of  the  same  kind  are  on  record.  At  present  I  recollect  only  the 
following:  1.  The  case  of  Professor  Mahon  noticed  by  Leroux,  Journ.  de  Med. 
Chir.  ri  I'lninn.  t.  ix.p.  L36.  2.  A  rase  by  Hohnbaum,  Ueber  den  SchlagfluSs, 
Krlangen.  1817,  p.  ?."..  3:  A  rase  by  lfa\  le,  Havit  Med.  Avril,  1828, p.  61.  4.  A 
ease  by  Andral,  Clinique  Mid.  t.  iii.  \>.  IG7.  5.  A  case  by  Dr.  Ferguson,  Dub. 
Med.  Trans.  New  Series.     Vol.  i.  p.  11. —  Transl. 


198  PULMONARY  APOPLEXY. 

manner  as  to  form  an  intimate  union  with  the  pulmonary  tissue, 
very  different  from  what  would  be  produced  by  the  mere  physi- 
cal coagulation  of  the  blood.  We  sometimes  find  two  or  three 
similar  indurations  in  the  same  lung,  and  frequently  both  lungs 
are  affected  at  the  same  time.  They  take  place  most  commonly 
in  the  central  parts  of  the  lower  lobe,  or  towards  the  middle  and 
posterior  part  of  the  lungs :  It  is  consequently  on  the  back  and 
inferior  part  of  the  chest  that  we  ought  to  search  for  them  with 
the  stethoscope. 

This  affection  is  as  easily  distinguishable  from  the  congestions 
that  take  place  after  death,  as  from  the  alterations  produced  by 
peripneumony.  The  sanguineous  congestions  of  the  dead  body 
consist  of  an  accumulation  of  blood  intermixed  with  serum,  often 
spumous,  which  flows  plentifully  on  an  incision  of  the  part,  and 
tinges  the  lungs  of  a  livid  or  vinous  color.  Being  the  mere 
consequence  of  gravitation,  the  engorgement  is  found  most  con- 
siderable in  the  most  depending  parts  of  the  lungs,  and  gradually 
lessens  towards  the  superior  parts.  Where  most  engorged,  the 
part  still  retains  some  crepitation,  and  the  incised  surfaces  are 
never  granulated,  even  when  the  congestion  is  so  great  as  to  de- 
stroy the  spongy  character  of  the  lung.  By  washing,  we  can,  in 
every  case,  remove  all  the  red,  and  restore  the  lung  to  that  sort 
of  flaccidity  which  it  possesses  when  compressed  by  a  pleuritic 
effusion.  The  engorgement  of  haemoptysis,  on  the  contrary,  is 
accurately  circumscribed,*  very  dense,  dark  red  or  brown,  gra- 
nulated, and  almost  dry  when  incised,  and  grows  pale  by  washing, 
but  without  losing  any  part  of  its  consistence.  Whatever  may 
be  the  severity  of  this  disease,  resolution  seems  to  take  place 
with  considerable- facility,  since  we  find  a  great  many  cases  of  re- 
covery after  severe  haemoptysis.  I  have  not  had  many  oppor- 
tunities of  tracing  the  progress  of  this  resolution  by  dissection  ; 
but  in  the  small  number  of  cases  of  this  kind  which  I  have  met 
with,  it  has  appeared  that  the  indurated  parts  passed  successively 
from  dark  red  to  brown  and  pale  red,  and  that,  in  proportion  as 
the  color  faded,  the  parts  lost  their  granular  texture  and  their 
density.  I  do  not  think  that  this  obstruction  is  followed,  at 
least  constantly,  by  oedema,  as  is  the  case  with  the  obstruction  of 
peripneumony.  When  the  resolution  is  complete,  it  leaves  no 
trace  of  disease  in  the  pulmonary  substance,  since  I  have  never 
been  able  to  find  any  vestige  of  the  induration  in  subjects  who 
had  been  affected  with  severe  haemorrhage  at  a  period  of  some 
years — or  only  some  months — anterior  to  their  death.f 

*  The  slow  haemorrhage  or  splc?iisation,  is  not  accurately  circumscribed ;  but 
it  is  sufficiently  distinguished  from  the  cadaveric  engorgement  by  its  other  char- 
acters, and  particularly  by  the  blackish  color  of  that  portion  of  the  pulmonary  tis- 
sue, wherein  it  is  seated. — (JU.  [_,.) 

t  Pulmonary  apoplexy  does  not  always  terminate  in  resolution.     The  pulmo- 


PULMONARY  APOPLEXY. 


199 


Signs  and  symptoms.  The  principal  symptoms  of  this  dis- 
ease are  the  following : — great  oppression,  cough  attended  by 
much  irritation  of  the  larynx,  and  sometimes  by  a  very  acute  pain 
in  the  chest ; — expectoration  of  bright  and  frothy  or  black  and 
clotted  blood,  quite  pure  or  merely  intermixed  with  saliva,  or 
some  bronchial  or  guttural  mucus ;  pulse  frequent,  full,  and 
with  a  particular  kind  of  vibration,  even  when  soft  and  weak,  as 
it  frequently  is  after  a  day  or  two.  There  is  rarely  any  positive 
fever,  and  the  heat  of  the  skin  continues  natural  or  nearly  so. 
Frequently  the  heart  and  arteries  yield  the  bellows-sound  in  a 
very  marked  degree,  the  character  of  which  phenomenon  will  be 
given  when  we  come  to  treat  of  diseases  of  the  heart.  Of  all 
these  symptoms  the  spitting  of  blood  is  the  most  constant  and 
most  severe.  This  is  commonly  very  copious,  returning  by  fits, 
with  cough,  oppression,  anxiety,  intense  redness  or  extreme  pale- 
ness of  face,  and  coldness  of  the  extremities.  When  the  haemor- 
rhage is  very  great  it  comes  on  sometimes  with  a  very  moderate 
degree  of  cough,  and  is  accompanied  by  a  convulsive  elevation 
of  the  diaphragm  like  that  which  takes  place  in  vomiting.  This 
accounts  for  the  expression — vomiting  of  blood,  which  is  used  by 
most  persons  who  have  suffered  a  violent  haemoptysis.  And  I 
am  of  opinion  that  this  expression  is  not  always  improperly  ap- 
plied in  such  cases.  It  is  hard  to  believe  that  those  immense 
and  instantaneous  discharges  of  blood,  partly  too  in  a  state  of 
coagulation,  which  burst  at  once  from  the  mouth  and  nostrils, 
and  fill  a  basin  in  a  few  moments,  can  proceed  entirely  from  the 
bronchi.  The  very  size  of  the  coagula  seems,  in  many  cases,  to 
render  this  impossible  ;  while  the  accompanying  action  of  vomit- 
nary  extravasations  may,  as  is  remarked  by  Cruvielhier,  (Op.  Cit.  Propos.  22), 
pass  through  the  same  stages  as  those  in  the  brain.  Thus,  the  pulmonary  lob- 
ules affected  with  apoplexy,  when  the  fluid  part  of  the  blood  is  absorbed,  may  be 
gradually  transformed  into  indurated  nodules  of  a  jet  dark  color,  and  which  ex- 
isting as  so  many  foreign  bodies  in  the  lungs,  become  isolated  by  means  of  a 
cyst,  in  the  same  way  as  takes  place  in  the  case  of  cerebral  effusions.  Perhaps 
it  may  be  in  this  way  that  the  encysted  melanosis,  to  be  noticed  in  a  subsequent 
part  of  this  work,  maybe  produced.  In  other  cases,  rare  indeed,  like  the  above, 
the  affected  parts  of  the  lung  become  softened  and  resolved  into  pus.  In  cases 
of  this  kind  we  find  in  the  lungs  real  cavities,  the  walls  of  which  are 
either  gorged  with  blood  or  exhibit  the  natural  appearance  of  the  pulmonary 
substance,  according  as  the  softening  has  been  more  or  less  complete ;  these 
cavities  contain  a  thick  fluid,  of  the  color  of  wine-lees,  and  consisting  of  a  mix- 
ture of  pus,  blood  and  pulmonary  detritus.  It  is  probable  that  excavations  of 
this  sort  may,  like  those  arising  from  tubercles,  become  lined  by  a  false  mem- 
brane, and  undergo  analogous  transformations  and  even  cicatrization.  Although 
the  hist  result  has  never  been  actually  observed,  the  analogy  is  so  strong  as  al- 
most to  stand  in  lieu  of  direct  proof;  it  being  infinitely  probable,  as  is  observed 
by  M.  Rousset,  that  the  pulmonary  cicatrices — so  frequent  that  out  of  twenty 
dead  bodies  four  at  least  will  be  found  to  exhibit  them — have,  in  a  considerable 
portion  of  cases,  been  the  consequence  of  an  apoplectic  extravasation  and  not  of 
phthisis,  which  is  not  likely  to  be  so  frequently  of  a  purely  local  character. — 
(M.  L) 


>200  PULMONARY    APOPLEXY. 


in"-  would  seem  to  confirm  the  co-existence  of  a  hacmateniGsis 
with  the  haemoptysis.  This  conjecture  I  have  sometimes  proved 
to  be  correct,  but  not  often  ;  as  it  is  not  very  common  to  find 
patients  die  during  the  very  course  of  a  severe  haemoptysis ; 
while,  on  the  other  hand,  I  have  sometimes  found  in  the  stomach 
only  a  very  small  quantity  of  blood,  (and  which  appeared  to 
have  been  swallowed,)  even  in  cases  where  the  haemorrhage  had 
been  accompanied  by  very  decided  efforts  to  vomit.  The  quan- 
tity of  blood  discharged  is  sometimes  enormous.  I  have  known 
ten  pounds  lost  in  forty-eight  hours,  by  a  young  man,  who  died 
under  the  haemorrhage.  In  cases  of  a  less  acute  character,  I 
have  seen  about  thirty  pounds  lost  in  a  period  of  fifteen  days. 
Rhodius  (Cent.  n.  obs.  xxx.)  relates  similar  instances.  Haemor- 
rhage so  severe  as  this  almost  always  indicates  the  existence  of  a 
hremoptysical  induration.  Yet  this  conclusion  is  not  always 
correct ;  since  we  have  already  seen  that  very  violent  discharges 
may  proceed  from  the  bronchi  alone  ;  while,  on  the  other  hand, 
there  may  exist  an  extensive  haemoptysical  infiltration,  although 
the  expectoration  of  blood  is  trifling,  for  instance,  not  more  than 
from  two  to  six  ounces  in  the  twenty-four  hours.  When  the 
infiltration  is  only  of  moderate  extent,  as  from  one  to  two  inches 
square,  there  may  be  no  expectoration  whatever  of  blood,  and 
the  disease  may  be  latent.  This  was  the  case  with  the  first  ex- 
amples of  this  disease  that  occurred  to  myself ;  and  I  was,  in 
consequence,  puzzled  to  what  disease  I  should  refer  the  morbid 
alteration,  of  which  I  had  previously  met  with  no  account.  Haller 
is  the  only  author,  who  to  my  knowledge,  has  given,  under  the 
name  of  peripneumony  from  exudation  of  blood,  a  brief  history 
of  a  disease  which,  from  the  account  of  the  state  of  the  lungs,  I 
consider  to  have  been  a  case  of  very  extensive  pulmonary  apo- 
plexy. It  is  probable  that  in  this  case  there  was  no  haemoptysis 
worth  noticing,  since  the  author  does  not  mention  it,  and  de- 
scribes the  disease  as  peripneumony.*  (Opusc.  Pathol,  obs.  xvi. 
hist,  i.) 

*  The  affection  described  in  the  preceding  pages  was  entirely  unknown  as  a 
common  cause  of  hemoptysis  before  the  publication  of  the  first  edition  of  our 
author's  treatise  ;  although  some  varieties  of  it  iiad  been  noticed  by  former 
writers,  and  the  name  of  pulmonary  apoplexy  applied  to  the  disease  by  one  or 
two  of  these.  In  1816,  M.  Leveill6 appears  to  have  read  a  memoir  on  ibis  sub- 
ject before  the  Academy  of  Sciences  at  Paris  ;  and  in  1817,  Dr.  Hohnbauni,  of 
Hildburghausep,  published  an  essay  on  a  disease,  which  he  designated  Pulmo- 
nary Apoplexy.  See  his  work  "  Uber  den  Lungenschlagfluss  nebsl  einer  Einlei- 
tung  iiibu-  Schlagflusse  vherhaupt."  Erlangen,  J-M7.  M.  Laennec's  Treatise 
was  not  published  until  1819.  But  no  preceding  writer  has  given  the  precise 
characters  of  the  disease  recorded  in  the  text,  ilolinbaum  had  met  with  only 
three  examples  of  the  disease  described  by  him  ;  and  as  there  may  besome  doubt 
whether  the  affection  is  the  same  as  that  described  by  Laennec,  or  one  of  a  dif- 
ferent kind.  I  shall  give  a  brief  outline  of  two  of  his  cases.  The  first  occurred  in 
a  man  forty  years  of  age,  who  had  been  a  very  free  liver,  was  subject  to  parox- 


PULMOMARY  APOPLEXY.  201 

From  what  precedes,  it  is  obviously  impossible  to  distinguish, 
by  the  symptoms  merely,    the    bronchial    from    the    pulmonary 

\  miis  of  asthma,  and  for  some  time  before  his  death  incapable  of  using  bodily  ex- 
ertion on  account  of  a  tightness  on  the  chest  which  was  produced  by  it.  With- 
out any  precursory  symptoms,  this  man  fell  down  seneless  as  if  struck  by  apo- 
plexy. On  examining  the  body  on  the  following  day,  the  brain  and  its  vessels 
were  found  quite  sound,  and  the  latter  rather  empty,  and  the  only  morbid  ap- 
pearances observed  were  in  the  chest.  Both  lungs  were  distended  with  dark- 
colored  blood  partly  coagulated  and  partly  fluid,  and  the  pulmonary  substance 
when  cut  in  slices  sunk  in  water.  The  same  kind  of  blood  was  found  in  the 
bronchi.  The  right  ventricle  of  the  heart  was  also  filled  by  it,  while  the  left 
contained,  only  half  an  ounce  of  it.  p.  72. 

The  subject  of  the  second  case  was  a  man  thirty  years  of  age,  who  had  also 
lived  well  and  was  fat.  He  had  been  considered  as  in  good  health,  except  that 
he  suffered  from  dyspnoea  and  head-ache  upon  attempting  the  slightest  exercise 
on  foot.  This  man  took  a  journey  in  a  carriage  in  a  very  cold  da}',  during  which 
he  drank  freely.  Upon  returning  at  night  he  was  found  dead  in  the  carriage, 
the  driver  having  some  time  before  observed  him  to  be  drowsy  and  somewhat 
inarticulate  in  his  speech,  which  he  attributed  to  intoxication.  The  brain  was 
found  perfectly  sound,  and  with  the  vessels  only  moderately  filled  with  blood, 
but  there  was  slight  partial  thickenings  and  adhesions  of  the  membranes.  Upon 
opening  the  chest  the  lungs  seemed  too  large  for  the  cavity,  distended  with  black 
blood,  and  almost  like  liver  when  cut  into.  The  back  parts  of  the  lungs  were 
most  filled  with  the  black  blood,  part  of  which  was  also  found  effused  in  the 
cavity  of  the  chest.  The  right  ventricles  of  the  heart  contained  several  ounces 
of  the  same  kind  of  blood — and  the  left  was  empty.  The  heart  and  larger  ves- 
sels were  sound,  p.  75.     In  neither  case  was  there  any  spitting  of  blood. 

Since  the  publication  of  Hohnbaum's  little  work,  and  the  first  edition  of Laen- 
nec's  treatise,  avast  number  of  rases  of  pulmonary  apoplexy  have  been  recorded 
by  different  authors,  the  principal  of  which  arc  referred  to  in  the  bibliographical 
notice  at  the  end  of  the  present  chapter,  and  various  opinions  have  been  advan- 
ced respecting  its  causes  and  nature. 

Hohnbaum,  Lorinser,  and  other  German  pathologists,  consider  it  as  depending 
on  a  sudden  paralysis  of  the  pulmonary  nerves,  with  a  consequent  comparative 
over-action  of  the  blood-vessels  of  the  lungs.  This  doctrine  of  local  palsy  and 
consequent  effusion  of  blood,  they  extend  to  all  the  principal  organs  of  the  body, 
naming  the  affection  apoplexy  wherever  it  occurs,  from  a  supposed  identity  of 
character  with  the  cerebral  disease  commonly  so  denominated.  Whether  the 
explanation  is  correctly  applied  or  not  to  the  affection  as  it  takes  place  in  other 
organs,  we  may  state  with  confidence  that  it  is  inapplicable  to  the  very  case 
which  serves  these  pathologists  as  a  proptotype, — cerebral  apoplexy  being  now 
well  ascertained  to  depend  generally  on  very  different  causes.  It  may,  how- 
ever, be  more  applicable  to  other  organs  than  to  the  brain  ;  and  some  counte- 
nance is  giv^en  to  this  doctrine  by  the  late  discoveries  of  Mr.  Charles  Bell,  and 
the  demonstration  by  him  and  Mr.  Shaw  of  the  existence  of  local  paralytic  affec- 
tions of  the  external  nerves. 

The  most  prevalent  opinion,  and  in  one  class  of  cases  unquestionably  the  true 
opinion,  is.  that  pulmonarv  apoplexy  depends  essentially  on  disease  of  the  heart, 
and  particularly  on  those  forms  of  disease  which  throws  a  preternatural  volume 
of  blood  into  the  pulmonary  vessels,  viz.  hypertrophy  of  the  right  ventricle  or 
contraction  of  some  of  the  orifices  on  the  left  side  of  the  heart,  or  both  conjoin- 
ed. This  view  of  the  case  seems  to  have  been  first  taken  many  years  ago  by  our 
countryman,  Allan  Burns  ;  and  the  whole  modus  operandi  of  the  cause  is  clearly 
explained  in  his  treatise  at  p.  51  et  seq.  He,  however,  lays  considerably  more 
stress  on  the  active  effect  of  the  hvpertrophied  right  ventricle,  than  on  the  pas- 
sive influence  of  obstructions  to  the  escape  of  blood  from  the  lung*  through  the 
pulmonary  veins.  But  he  notices  this  last  also  in  the  section  "  On  the  Effects  of 
Change  of  Structure  in  the  Valves,"  p.  163.  "  We  shall  take  it  for  granted,"  he 
saysj  "  that  the  [  right]  auricle  and  ventricle  are  each  of  them  dilated  so  far  as  ea- 
sily to  contain  three,  ounces  (in  place  of  tico,  as  he  had  supposed  the  case  in 
health)  of  fluid,  but  that  the  pulmonary  artery  remains  of  its  usual  size.     If  the 

26 


202  PULMONARY  APOPLEXY. 

hemorrhage.  This  end  is  frequently  attained,  however,  by 
means  of  the  physical  signs  afforded  by  percussion  and  ausculta- 
tion. The  haMnoptysical  engorgement  is  usually  of  too  small 
extent  to  be  recognizable  by  percussion  ;  and,  besides,  it  fre- 
quently has  its  seat  in  those  portions  of  the  lungs  which  are 
beyond  the  reach  of  this  means  of  diagnosis.     However,  when  it 

ventricle  propels  the  whole  of  this  blood,  tlie  consequence  must  be  terrible;  the 
ultimate  branches  of  this  vessel  in  the  lungs  will  give  way."  p.  52.  '•  The  pul- 
monic vessels,  by  the  congestion  and  continued  eis  a  terga,  arc  ruptured  ;  blood 
is  forced  into  the  air  cells  ;  haemoptysis  is  produced  ;  or,  if  urged  sjill  further,  all 
the  cellular  structure  of  the  lungs  is  crammed  with  blood  ;  these  organs  cut  like 
liver,  and  sink  when  put  into  water.  This  I  am  convinced  from  repeated  obser- 
vations is  a  frequent  cause  of  haemorrhage  from  the  lungs  ;  and  I  have  seen  sev- 
eral who  have  lost  their  lives  from  not  preserving  the  muscular  action  within  pro- 
per limits."      Obs.  on  Dis.  of  the*  Heart.     Edin.  1800.     8vo.  p.  53. 

The  same  explanation  of  the  disease  is  given  by  M.  Bertin,  (Traite  de  Mala- 
dies du  Cceur,  p.  352.)  by  Bayle,  (Revue  Med.  Avril,  1828,)  by  Hope,  Dis,  of  the 
Heart,  pp.  197,  211,  and  by  M.  Andral,  (Clinique  Medicale,  p.  518  :)  and  the  lat- 
ter author  further  considers  the  pulmonary  apoplexy  as  differing  from  the  com- 
mon bronchial  haemorrhage  in  no  other  respect  except  that  the  effusion  of  blood 
in  the  former  takes  place  into  the  very  minute  bronchial  ramifications,  instead 
of  the  larger  bronchi,  as  in  the  latter  affection.  A  review  of  the  other  very  nu- 
merous cases  of  pulmonary  apoplexy  recorded  by  authors,  places  in  a  striking 
point  of  view  the  effects  of  disease  of  the  heart  in  producing  it,  as  this  complica- 
tion will  be  found  in  the  great  majority  of  the  examples.  Dr.  Townsend  in- 
forms us,  that  out  of  twenty-one  cases  examined  by  himself,  fifteen  occurred  in 
individuals  laboring  under  diseased  hearts.  (Cyc.  of  Pract.  Med.  i.  138;)  and 
we  are  disposed  to  regard  this  as  not  exceeding  the  general  proportion  of  such 
cases.  A  very  ingenious  and  rising  young  member  of  our  profession,  Mr.  Hen- 
ry Johnson,  has  recorded  four  cases  of  this  disease  occurring  under  his  own  no- 
tice, within  a  short  space  of  time  at  St.  George's  Hospital,  all  of  which  were 
complicated  with  contraction  of  the  left  auriculo-vertirular  orifice  ;  and  he  has 
endeavored  to  establish  a  more  definite  relation  between  pulmonary  apoplexy 
and  this  form  of  cardiac  disease  than  between  it  and  any  other  affection  of  the 
heart,  a  view  which  is  adopted  by  Dr.  Hope,  (Dis.  of  the  Heart,  p.  197.)  The 
same  observation  was  made  made  by  Burns,  who  says,  <;  when  the  mitral  valve 
is  obstructed  we  find  that  the  blood,  impelled  by  the  pulmonary  artery,  meeting 
in  its  course  a  back  stroke  from  the  left  auricle,  produces  rupture  of  the  minute 
branches  of  those  vessels  in  the  lungs."  p.  185. 

There  can,  therefore,  be  no  doubt,  that  many  cases  of  pulmonary  apoplexy, 
are,  as  these  authors  suppose,  owing  to  diseased  heart ;  jet  I  think  those  best 
deserving  this  name;  for  instance,  those  described  by  Hohnbaum,  the  case  by 
Corvisart,  and  that  by  Haller,  can  hardly  be  attributed  to  this  cause  alone.  It  is 
not  improbable  that  some  of  the  instances  of  sudden  death,  usually  attributed  to 
cerebral  apoplexy,  or  disease  of  the  heart,  may  depend  upon  the  disease  descri- 
bed by  Hohnbaum.  In  these  cases,  may  not  the  state  of  the  blood  itself  be  some- 
times the  cause  of  the  disease?  At  all  events,  I  am  disposed  to  consider  a, pre- 
ternatural slowness  of  transmission  of  the  blood  through  the  lungs,  whether  de- 
pending on  organic  disease  or  not,  as  one  predisposing  cause  of  this  affection. 
It  is  in  this  way  I  would  account  for  the  frequent  occurrence  of  haemoptysis 
under  the  influence  of  the  depressing  passions  ;  and  the  pathology  of  which  af- 
fection I  would  illustrate  by  referring  to  the  physiology  of  . sig /',;'„  g.  Some  of 
the  most  severe  instances  of  pulmonary  haemorrhage  that  has  come  to  my  knowl- 
edge, have  originated  under  the  influence  of  grief  and  anxiety  ;  and  I  look  upon 
moral  causes  of  this  kind  as  a  fertile  source  of  many  anomalous,  yet  most  dis- 
tressing functional  affections  of  the  lungs  and  heart.  This  view  of  such  cases 
seems  to  me  explanatory  of  that  singular  effect  of  nostalgia  noticed  and  descri- 
bed by  Avenbrugger,  viz.  an  induration  of  one  lung,  with  consequent  absence  of 
the  natural  sound  on  percussion,  terminating  fatally.  See  my  Translation  of 
Avenbrugger  in  Original  cases,  &c.  p.  24.—  Transl. 


PULMONARY  APOPLEXY. 


203 


exists  to  a  pretty  considerable  extent,  percussion  elicits  a  dull 
sound  over  the  corresponding  parts  of  the  chest ;  and  I  have 
met  with  instances  where  this  was  the  case  over  the  third  part  of 
one  of  the  sides.  The  stethoscope  furnishes  us  with  two  prin- 
cipal signs  of  this  affection — the  want  of  the  sound  of  respiration 
over  a  small  circumscribed  space,  and  crepitous  rhonchus  around 
this  space.  This  rhonchus,  which  here  indicates  the  slight  infiltra- 
tion of  blood  formerly  described,  is  always  found  at  the  com- 
mencement of  the  disease,  but  is  frequently  wanting  in  the  latter 
stages.  When  these  signs  co-exist  with  pulmonary  haemorrhage, 
we  may  be  assured  that  the  site  of  the  discharge  is  in  the  pul- 
monary substance,  and  not  in  the  bronchi  simply.  In  the  one 
case,  however,  as  well  as  the  other,  there  is  found,  at  the  roots 
of  the  lungs  more  particularly,  a  mucous  rhonchus  with  large 
bubbles.  These  bubbles  seem  to  be  larger,  thinner,  and  formed 
by  a  matter  more  liquid  than  mucus  ;  they  also  burst  more  fre- 
quently, and  with  a  peculiarity  of  sound  which  cannot  be  mis- 
taken. 

The  haemoptysical  engorgement  is,  moreover,  frequently  ac- 
companied by  an  exudation  of  blood  from  the  bronchial  mem- 
brane, which  is  almost  always  found  much  reddened,  swollen,  and 
somewhat  softened,  when  the  engorgement  is  of  some  extent, 
and  more  particularly  in  its  vicinity.  When  the  induration  is 
extensive,  the  absence  of  sound  on  percussion,  joined  with  the 
preceding  signs,  leaves  no  doubt  of  the  nature  of  the  disease,  and 
prevents  its  being  confounded  with  any  other  except  peripneu- 
mony  ;  and  this  only  in  cases  where  the  spitting  of  blood  is  very 
inconsiderable.  It  is  true  that  in  both  these  diseases,  there  exists 
the  same  crepitous  rhonchus,  and  also  the  same  want  of  respira- 
tion and  sound  on  percussion  ;  but  the  local  and  general  symp- 
toms being  entirely  different  in  the  two  cases,  there  can  very 
rarely  be  any  doubt  about  the  diagnosis.  When  the  two  dis- 
eases arc  combined,  a  thing  which  is  of  rare  occurrence,  the 
diagnosis  is  more  difficult.*  When  a  pneumonia  supervenes 
during  the  resolution  of  a  haemoptysical  induration,  there  is  a 
recurrence  of  the  crepitous  rhonchus,  without  any  fresh  discharge 
of  blood,  or  with  an  expectoration  of  sputa  tinged  with  blood, 
but  possessing  the  tenacity  of  those  of  peripneumony.  The  con- 
comitance of  fever  in  the  case  of  inflammation,  tends  further  to 
strengthen  the  diagnosis.  It  is  hardly  necessary  to  remark,  that 
when   the  haemoptysical   infiltration  is   suddenly  formed,  so   as 

*This  complication,  according  to  M.  Rousset,  is  accompanied  so  constantly  by 
one  symptom  that  it  may  be  regarded  as  pathognomonic  :  it  is  this;  the  expec- 
toration is  very  copious  and  very  fluid,  appearing  black  when  at  rest,  but  pre- 
senting, when  agitated,  a  color  like  that  of  a  solution  of  extract  of  liquorice. — 
(Op.  Cit.  p.  35.;— (M.  L.) 


204  PULMONARY    APOPLEXY. 

instantly  to  occasion  suffocation,  as  in  Corvisart's  case,  there  in 
no  time  for  the  occurrence  of  external  haemorrhage.  When  the 
lesion  is  of  small  extent,  and  the  failure  of  respiration  in  the 
affected  part  cannot  on  this  account  be  discovered,  it  is  some- 
times difficult  to  determine  whether  the  haemorrhage  is  simply 
bronchial  or  not.  In  the  beginning  of  the  attack,  the  presence 
of  the  crepitous  rhonchus  will  decide  the  question ;  later  in  the 
disease,  the  decision  will  be  more  difficult ;  but  uncertainty  in 
this  case  is  of  no  practical  importance.  The  crepitous  rhonchus 
is  by  no  means  so  constant  during  the  resolution  of  haemoptysis  as 
during  that  of  peripneumony.* 

Occasional  causes. — These  are  in  general  the  same  as  those  of 
the  bronchial  haemorrhage.  It  is  to  be  remarked,  however,  that 
the  spitting  of  blood  which  accompanies  the  formation  of  tuber- 
cles, is  most  frequently  of  the  latter  species ;  while  that  which 
occurs  in  subjects  affected  with  disease  of  the  heart,  is  most  com- 
monly in  the  former  kind.f  The  suppression  of  habitual  dis- 
charges— such  as  the  menses,  haemorrhoids,  or  epistaxis — gives 
occasion  to  both  kinds  indifferently.  Plethora  and  the  sudden  or 
long-continued  impression  of  excessive  heat  or  cold,  ought  also  to 
be  numbered  among  the  occasional  causes  of  this,  as  of  many 
other  diseases  of  a  very  different  kind  ;  but,  in  most  cases,  such 
causes  are  merely  simple  occasions,  which  could  not  of  themselves 
have  given  rise  to  the  disorder,  without  some  peculiarity  of  con- 
stitution in  the  individuals. 

It  appears  to  me  impossible  to  witness  the  immense  losses  of 
blood  which  sometimes  have  taken  place  in  haemoptysis  or  mo- 
norrhagia,— or  the  congestions  which  occur  suddenly,  and  at  the 
same  instant,  in  all  the  internal  and  external  organs,  in  epilepsy 
and  certain  cases  of  hysteria,  without  admitting,  that  the  blood 
in  such  cases  experiences  a  sudden  dilatation.  We  know  that 
on  mountains  sufficiently  elevated  to  occasion  considerable  dimi- 
nution of  the  atmospheric  pressure,  most  persons  spit  blood,  and 

*  When  pulmonary  apoplexy  terminates  by  the  softening  of  a  portion  of  the 
indurated  lung  and  the  consequent  formation  of  an  abscess,  it  may  chance  that 
this  may  suddenly  burst  into  the  broncjii  and  give  rise  to  a  sort  of  vomica.  In 
this  case,  the  patient  expectorates  a  large  quantity  of  a  dirty  red  liquid,  contain- 
ing small  specks  like  those  we  observe  swimming  in  water  in  which  fresh  flesh 
has  been  washed,  and  immediately  afterwards  pectoriloquy  will  be  found,  evinc- 
ing the  emptying  of  the  excavation.  M.  Rousset  on  two  occasions  verified  the 
existence  of  hcemoptysical  abscess  by  this  sign,  as  was  proved  by  examination 
after  death.  "  In  other  cases,  however,"  observes  M.  Rousset,  "  the  pulmonary 
tissue  being  gradually  expectorated  as  it  becomes  liquified,  the  excavation  is 
formed  slowly,  and  the  quantity  of  matter  expectorated  at  one  time  is  too  small 
to  enable  us  to  come  to  a  like  conclusion."— (Op.  Cit.  p.  33.)— (M.  L.) 

t  I  have  found  the  lesion  which  characterises  pulmonary  apoplexy  more  often 
in  persons  who  have  died  of  organic  diseases  of  the  heart,  than  in  any  other.— 
Andral. 


PULMONARY    APOPLEXY. 


205 


that  in  severe  haemorrhages  the  blood  is  more  liquid  and  less  coag- 
ulable  than  natural.* 

Treatment. — This  must  be  the  same  as  in  the  bronchial 
haemorrhage ;  but  the  extreme  danger  which  attends  the  hae- 
moptysical  induration  and  the  possibility  of  its  resolution,  ought 
to  make  us  boldly  use  copious  venesection  from  the  onset  of  the 
disease.  One  blood-letting  of  twenty  or  twenty-four  ounces  on 
the  first  or  second  day,  will  have  more  effect  in  "checking  the 
haemorrhage  than  several  pounds  taken  away  in  the  course  of  a 
fortnight.  It  is  even  beneficial  in  general  to  induce  partial  syn- 
cope by  means  of  the  first  bleeding.  In  cases  of  this  kind,  the 
fear  of  exhausting  the  patient's  strength  is  without  grounds,  since 
we  know  that  the  most  copious  venesection  falls  short  of  the  loss 
of  blood  sustained  from  pulmonary  haemorrhage,  in  young  and 
robust  subjects,  even  in  the  course  of  a  few  minutes ;  while  the 
debilitating  effect  of  the  haemorrhage  is  infinitely  greater  than  the 
loss  of  blood  produced  by  the  lancet.  Should  the  haemorrhage 
continue  after  the  pulse  has  become  small  and  weak,  and  the 
strength  much  reduced,  it  will  not  be  prudent  to  employ  further 
venesection,  but  to  have  recourse  to  derivatives,  among  which 
purgatives  are  unquestionably  the  most  efficacious.  A  drastic 
enema  or  cathartic  frequently  checks  the  haemorrhage,  and  even 
the  haemorrhagic  molimen,  especially  if  they  are  productive  of 
faintness.  This  practice  may  perhaps  appear  bold  to  many 
practitioners  ;  but  it  has  the  sanction  of  Sydenham ;  and  I  have 

*  I  am  far  from  denying  the  influence  of  elevated  regions  in  causing  or  ac- 
celerating haemoptysis ;  this  fact  is  well  established.  But  it  is  not  equally 
well  demonstrated  that  this  arises  from  a  diminution  of  atmospheric  pressure. 
In  the  first  place,  this  diminution  is  very  trifling  in  most  of  those  elevated 
regions  where  the  air  brings  on  haemoptysis  in  phthisical  patients  ;  besides,  it 
is  only  those  persons  whose  lungs  are  already  diseased,  or  at  least  inclined  to 
disease,  that  are  brought  in  this  way  to  spit  blood.  In  the  second  place,  travel- 
lers in  the  most  elevated  regions  of  the  globe  have  given  us  only  a  single  rela- 
tion of  the  occurrence  of  haemoptysis — and  this  was  given  by  Bouguer  in  his 
travels  among  the  Cordilleras  :  and  he  stafes  that  the  haemorrhage  was  mode- 
rate, and  took  place  only  in  those  of  his  companions  who  had  delicate  lungs. 
Nothing  of  the  kind  was  remarked  by  Saussure  either  in  himself  or  his  com- 
panions, during  their  journey  to  the  summit  of  Mount  Blanc.  In  the  accounts 
given  \y  M.  M.  Bouissingault,  D'Orbigny,  Roullin,  of  the  modified  sensations 
experienced  by  them  while  ascending  the  lofty  mountains  of  America,  no  men- 
tion is  made  of  spitting  blood.  Finally,  l\i .  Gay-Lussac  says  nothing  of  it  in 
the  account  of  his  ascension  in  a  balloon,  in  which  he  rose  to  the  height  of 
7,016  metres  above  the  level  of  the  sea.  Further,  in  all  these  accounts  we  read 
that  the  respiration  grew  difficult  the  higher  they  ascended,  while  the  circula- 
tion became  accelerated.  It  is  clear  then,  that  excessive  rarefaction  of  the  air 
forces  those  who  breathe  it  to  respire  rapidly  ;  and  the  physiological  reason  of 
this  is  easily  understood  :  but  in  these  cases,  the  frequent  occurrence  of  haemop- 
tysis has  been  rather  imaginary  than  real ;  and  if  phthisical  persons  who  go  to 
reside  in  elevated  regions  are  peculiarly  liable  to  haemoptysis,  this  is  less  owin^ 
to  the  rarefaction  of  the  air,  which  is  very  trifling  in  most  of  the  places  resorted 
to,  than  to  the  other  qualities  of  the  air,  which,  in  ascending,  becomes  dryer, 
more  exciting,  and  moves  with  greater  rapidity  and  force. — JindraL 


•206  PULMONARY    APOPLEXY. 

employed  it  with  success  in  cases  of  great  severity.  I  have  never 
seen  any  inconveniences  of  consequence  result  from  it ;  and  con- 
sider it  as  unquestionably  preferable  to  the  common  practice  of 
bleeding  to  eight  or  sixteen  ounces,  daily,  for  several  successive 
days,  and  through  the  period  of  a  whole  month.*  As  a  general 
rule  it  is  proper,  in  cases  which  appear  to  originate  in  the  sup- 
pression of  some  other  discharge,  to  make  the  artificial  loss  of 
blood  derivative ;  but  the  application  of  leeches  to  the  vulva  or 
anus  in  such  cases,  must  be  deferred  until  after  the  vascular  sys- 
tem is  unloaded  by  one  large  bleeding  from  the  foot  or  arm.  It 
occasionally  happens  that  both  local  and  general  bleeding,  in  place 
of  proving  derivative,  seem  on  the  contrary,  to  excite  haemorrhage. 
I. have  noticed  the  return  of  the  menses,  and  aggravation  of 
menorrhagia,  during  the  application  of  leeches  to  the  epigastrium. 
General  bleedings,  more  particularly  those  of  small  extent,  appear 
sometimes  to  have  a  like  effect  on  haemoptysis ;  and  cases  of 
this  kind  are  clearly  those  in  which  purgatives  should  have  a 
trial.f 

*  I  can  here  add  my  testimony  to  that  of  Laennec.  I  have,  like  him,  learn  1 
by  experience  the  great  use  of  purgatives  in  many  cases  of  haemoptysis.  I  do 
not  hesitate  to  repeat  them  several  times  even  in  eases  characterised  by  great 
febrile  excitement.  Except  in  cases  where  a  strong  general  reaction  is  evident, 
I  do  not  think  it  advantageous  to  practise  free  and  repeated  bleeding  until  the 
hoemoptvsis  is  arrested.  I  have  known  cases  where  such  a  course  of  treatment 
has  only  prolonged  the  haemorrhage.  The  patient  becomes  exhausted  by  such 
practice  and  is  reduced  to  a  state,  of  serious  debility;  moreover,  if  tubercles 
exist  in  the  lungs,  as  is  commonly  the  case,  their  development  is  accelerated  by 
the  state  of  exhaustion  to  which  the  whole  organization  becomes  reduced.  I 
think  that  in  similar  cases  we  ought,  on  the  contrary,  to  support  to  a  certain 
extent,  the  powrers  of  the  system,  and  consequently  I  consider  as  pernicious  the 
practice  of  some  physicians  who  prescribe  a  severe  diet  whenever  the  slightest 
trace  of  blood  is  observed  in  the  sputa.  I  have  known  haemoptysis  to  be  pro- 
tracted a  long  time  by  such  a  course,  and  to  have  subsided  only  when  the 
patient  was  allowed  more  substantial  food  and  a  moderately  tonic  beverage. 
Further,  in  these  cases,  we  must  not  be  too  much  afraid  of  allowing  the  patient 
to  leave  his  lied,  to  change' the  air  he  breathes,  or  to  indulge  in  moderate  exer- 
cise.— AndroX. 

t  For  the  first  part  of  the  following  note  on  this  passage  I  am  indebted  to 
my  friend,  Dr.  James  Clark.  "  This  fact  is  not  generally  known,  though  it  is 
one  of  great  practical  importance.  In  a  plethoric  person  threatened  with 
apoplexy  of  the  brain,  or  haemoptysis,  the  application  of  leeches  may,  and  I 
believe  frequently  does,  decide  the  very  occurrence  of  the  disease  it^vas  in- 
tended to  prevent.  I  have  more  than  once  seen  slight  haemoptysis  follow  the 
application  of  leeches  round  the  anus,  (and  have  warned  patients  not  to  be 
alarmed  at  it)  when  applied  to  obviate  pulmonary  haemorrhage.  In  one  case, 
a  severe  attack  of  haemoptysis  took  place  a  few  hours  after  the  application  of 
the  leeches,  requiring  general  bleeding,  &c.  A  very  small  bleeding  may  also, 
as  Laennec  observes,  produce  the  same  effect;  but  independentlv  of  the  quan- 
tity of  blood  abstracted,  there  is  a  sympathetic  effect  produced  on  the  extreme 
vessels  by  the  action  of  the  leeches  or  the  consequent  flow  of  blood  from  their 
punctures,  which  is  very  desirable  and  useful  when  we  wish  to  promote  a  san- 
guine secretion,  as  the  menses  ;  but  may  be  injurious  when  we  wish  to  obviate 
an  effusion  of  blood  from  the  extreme  Vessels  ;  a  general  bleeding  is  by  far  the 
better  practice  in  the  cases  under  consideration." 

A  remarkable  statement  of  M.   Broussais  on  the  effect  of  bleeding  in   cases 


PULMONARY  APOPLEXY.  207 

In  the  pulmonary  apoplexy,  still  more  than  in  the  bronchial 
haemorrhage,  it  is  of  importance  to  have  recourse  to  the  means 
formerly  recommended,  after  Sydenham,  for  preventing  a  relapse. 
Dry  cupping  over  the  whole  trunk  and  extremities,  after  general 
and  local  bleeding,  is  one  of  the  best  means  which  we  can  em- 
ploy. Blisters  and  sinapisms  are  of  less  frequent  benefit ;  and 
the  irritation  produced  by  them  seems  occasionally  to  be  propa- 
gated to  the  interior  of  the  chest. 

In  two  or  three  desperate  cases  I  have  tried  the  tartar  emetic 
in  large  doses,  in  the  manner  which  will  be  described  in  the  next 
chapter;  and  have  never -seen  any  bad  effect  from  it.  On  the 
contrary,  it  appeared  to  lessen  the  discharge  considerably ;  but  it 
did  not  certainly  produce  the  same  admirable  results  as  in  the 
case  of  inflammatory  diseases. 

When  the  haemorrhage  has  become  in  some  degree  chronic, 
partial ,  shower  baths  (by  means  of  a  watering  pot)  gradually 
changed  from  tepid  to  cold,  are  frequently  of  great  service;  and 
it  is  always  proper  to  make  the  patient  get  up,  every  now  and 
then,  in  order  to  keep  the  body  cool.  In  the  present  case,  still 
more  than  in  the  bronchial  haemorrhage,  we  must  not  give 
astringents  and  bitters  until  the  disease  has  assumed  a  chronic 
character.  The  patient  must  be  kept  to  the  strictest  regimen, 
more  particularly  in  the  onset  of  the  disease  ;  but  if  the  discharge 
is  prolonged,  we  must  allow  some  liquid  aliment,  and  gradually 
increase  this  as  the  strength  decreases  and  the  spitting  of  blood 
becomes  less.* 

where  much  blood  has  been  previously  lost,  whether  from  haemorrhage  or  other- 
wise, deserves  notice  in  this  place.  He  says  that  local  bleedings  are  often  in- 
jurious in  chronic  inflammations  of  the  "viscera  where  the  stock  of  blood  is  small, 
as  they  usually  increase  the  congestion  already  existing  in  them.  (Doctrines 
Mril.  Prep.  2(>7.  p.  Ixv.)  In  another  place  (Ibid.  vol.  i.  p.  1 1."))  he  says — '•'  where 
tin-  loss. of  blood  lias  been  too  great  for  the  demands  of  the  system,  the  fluids  of 
the  secondary  and  less  important  organs,  are  attracted  to  the  chief  viscera,  im- 
mediately concerned  in  the  preservation  of  life.  Withdraw  from  the  heart,  the 
brain,  the  lungs,  the  stomach,  their  necessary  and  indispensable  stimulus,  the 
blood  and  its  constant  attendant,  caloric — and  immediately  the  materials  of  life 
(materiaux  de  la  vie)  rush  from  all  the  other  parts  of  the  body,  which  have  not 
so  instant  a  demand  for  them."  This  statement — may  I  term  it  fact? — is  of 
great  practical  importance.  It  seems  corroborated  by  the  result  of  the  experi- 
ments made  by  Dr.  Seeds  and  Dr.  Kellie,  in  bleeding  animals  to  death  ;  (see  the 
firel  volunir  of  the  Transac.  of  the  Edin.  Med.  and  Chir.  Society;)  and  I  have 
myself  observed  many  facts  in  practice  which,  in  my  mind,  tend  to  confirm  its 
truth. —  Trail.--!. 

*  LITERATURE  OF  PULMONARY  APOPLEXY. 

I7.V>.   Haller.     Opusc.  Pathol.  Obs.xvi.  Hist.  i.     Lausan.  8vo. 

1808.  Corvisart,     Nouvelle  Methode,  &c.  par   Avenhrugger,  p.  227.     Par.  8vo, 

L809.  Hums  (Allan,)  Obs.  on  Diseases  of  the  Heart.     Edin  8vo. 

ISI7.   Hohnbaum  (C.)     Ueber  den  Lungenschlagfluss.     Erlang.  8vo. 

1824.  Bertin  et  Bouillaud.  Traite  des  maladies  du  creur,  p.  351.     Par. 

1834.  Chomel.     Diet,  de  Med.  (Art.  Hcmoptysic.)  t.  xi. 


'208  PNEUMONIA. 


CHAPTER  VI. 


OF    PNEUMONIA. 


Under  the  terms  peripneumonia  and  pneumonia,  the  ancients 
comprehended  all  the  acute  diseases  of  the  chest  which  are  un- 
accompanied by  any  marked  pain  of  the  side.  With  most  modern 
writers,  I  shall  limit  their  application  to  the  single  case  of  inflam- 
mation of  the  pulmonary  substance.  This  disease  is  one  of  the 
severest  and  most  common,  and  in  cold  and  temperate  climates, 
is  productive  of  more  deaths  than  any  other  acute  disease.  It 
has  on  this  account  much  engaged  the  attention  of  medical  men, 
who  have  examined  it  under  various  points  of  view.  In  the  pre- 
sent chapter  I  shall  treat  of  it  under  the  following  heads:  1. 
acute  pneumonia,  and  its  terminations  by  resolution  and  suppu- 
ration ;  2.  partial  pneumonia,  and  pulmonary  abscess ;  3.  gan- 
grene of  the  lungs  ;  4.  chronic  pneumonia  ;  and  5.  latent  and 
symptomatic  pneumonia.  I  shall  not  speak  of  pleuro-pneumonia, 
or  inflammation  of  the  lungs  complicated  with  pleurisy,  until 
after  I  have  treated  of  the  latter  disease.  I  shall  then  likewise 
examine  the  question,  so  much  agitated  during  the  last  century, 
of  the  distinction  between  those  two  diseases,  contenting  myself 
at  present  with  stating  that  nothing  is  more  common  than  to  find 
pneumonia  altogether  simple,  or  complicated  only  with  so  slight 
a  degree  of  pleurisy,  as  in  no  respect  to  add  to  its  danger  or 
modify  its  progress. 

Sect.  I.  Anatomical  characters  of  Acute  Pneumonia. 

Considered  in  an  anatomical  point  of  view,  pneumonia  presents 
three  degrees,  or  stages,  very  distinctly  marked  and  easily  recog- 

1826.  Andral.     Clinique  Med.  I.  iii.p.  164,  518.     Par.  8vo. 

1826.  Boullaud.     Archives  Gen.  de  Med.  Nov.  1826. 

1827.  Bright  (R.,  M.  D.)     Med.  Reports,  vol.  i.  p.  121.     Lond.  4to. 

1828.  Bayle  (A.  L.  J.,)     Revue  Medicale.  (p.  65)  Avril,  1824. 
1828.  Cruveilhier.     Anat.  Pathol.  Liv.  iii.  Par. 

1828.  Pingrenon.     Revue  Med.  p.  213.  Nov.  1828. 

1829.  Cruveilhier.     Diet  de  Med.  Pract.     (Art.  Jpoplcxie.)  t.  iii.  Par. 

1830.  Johnson  (H.)     Med.  Chir.  Rev.  (N.  S.)  vol.  xii.  p.  555.     Lond.  8vo. 
1830.  Ferguson  (J.  C.)     Dub.  Med.  Trans.  (N.  S.)  vol.  i.  p.  11.     Dub.  8vo. 
1830.  Law  (A.  M.)     Dub.  Med.  Trans.  (N.  S.)  vol.  i.  p.  89.     Dub.  8vo. 
1832.  Johnson.     Med.  Chir.  Rev.  vol.  xvi.  p.  473.     Lond. 

1832.  Hope  (J.,  M.D.)     Treatise  on  dis.  of  the  Heart  (p.  197,  211.)     Lond. 

1833.  Townsend.  Cyc.  of  Pract.  Med.  vol.  i.  p.  134.     Lond. 
1833.  Hope  (J.,  M.D.)     Morbid  Anat.  p.  38.     Lond. 

Plates  exhibiting  Pulm.  Jpoplez.  Cruveilhier,  Pathol.  Anat.  liv.  iii.  fig.  2,3. 
Carswell,  Pathol.  Anat.— Hope  Morbid.  Anat.  fig.  12,  32,  33,  34.—  TransL 


PNEUMONIA. 


209 


nized,  which  I  shall  distinguish  by  the  terms  engorgement  or 
inflammatory  congestion — hepatization — and  purulent  infiltra- 
tion. 

First  degree  (engorgement.) — In  this  degree  the  lung  is  exter- 
nally of  a  livid  or  violet  hue,  heavier,  and  much  more  solid  than 
natural.  It  is,  however,  still  crepitous,  but  much  less  so  than 
in  a  sound  state,  and,  on  pressing  it  between  the  fingers,  we 
perceive  that  it  is  injected  by  a  liquid.  It  retains  the  impression 
of  the  fingers  nearly  like  an  oedematous  limb.  When  cut  into, 
it  appears  of  a  livid  or  blood  color,  is  quite  injected  with  a 
frothy  serous  fluid,  more  or  less  sanguineous,  which  flows  from 
it  abundantly.  We  can  still,  however,  discover  very  clearly, 
the  natural  alveolar  and  spungy  texture  of  the  viscus,  except  in 
some  points,  where  the  obstruction  is  more  solid  and  compact, 
indicating  the  transition  from  the  first  to  the  second  degree  of 
pneumonia.  This  is  the  condition  of  lung  entitled  by  M.  Bayle 
engorgement  (engouement.*) 

Second  degree  (hepatization.) — In  this  degree  the  lung  has 
entirely  lost  its  crepitous  feel  under  the  finger,  and  has  acquired 
a  consistence  and   weight  altogether  resembling  those  of  liver. 
From    this   circumstance,  modern    anatomists    have    named  this 
condition  of  the  organ  hepatization  or  carnification.     The  former 
of  these  terms,  which  seems  to  have  been  first  used  by  Lcelius  a 
Fonte,  is    sufficiently  correct ;    the  last  is  very    improper,   and 
would  be  more  applicable  to  a  morbid  condition  of  the  lungs  to 
be  hereafter  described.     In  this,  the  second  degree  of  inflamma- 
tion,  the  lungs  are   frequently  less  livid  externally  than  in  the 
first   variety ;  but  they  exhibit  in  their  interior  a   redness  more 
or  less  deep,  which  varies  in  different  points  from  that  of  violet- 
grey  to    blood-red.      With  these  different  colors,  which  shade 
into  each   other  like  those  of  certain  marbles,  a  striking  contrast 
is  formed  by  the  bronchial  tubes,  the  blood-vessels,  the  specks 
of  black  pulmonary  matter,  and  the  thin  cellular  partitions  which 
divide  the  pulmonary  substance  into  portions  or  lobules  of  un- 
equal size.     These  partitions,  which  in  a  sound  state  of  the  organ 
are  not  easily  perceived,  become  now  more  distinct.     They  fre- 
quently  seem  to   be  unaffected  by  the  inflammation,  or  to  be 
affected  in  a  less  degree,  and  their  whiteness  consequently  ren- 
ders them  sometimes  extremely  distinct.     If  we  cut  in  pieces  a 
portion  of  lung  in  this  state,  hardly  any  fluid  escapes  from  it ; 
but  if  we  scrape  the  incised  surfaces   with  the  scalpel,  a  small 
quantity  of  a  bloody  serum  is  expressed,  which  is  more  turbid 
and  thicker  than  that  formerly  mentioned,  and  intermixed  with 

"For  want  of  a  proper  English  term   answering  to  this,  I  shall  use  congestion 
or  engorgement  in  the  limited  sense  in  which  engouement  is  used  in  the  text. — 

Transl. 

27 


210  PNEUMONIA. 

which  we  frequently  observe  another  kind  of  fluid,  thicker, 
opaque,  whitish,  and  puriform.  When  the  incised  surfaces  are 
exposed  to  the  light  in  a  proper  direction,  the  pulmonary  substance 
has  lost  entirely  its  cellular  appearance,  and  presents  a  granular 
aspect,  as  if  composed  of  small  red  grains,  oblong,  and  somewhat 
flattened.  This  granular  texture  appears  to  me  the  distinguish- 
ing anatomical  characteristic  of  inflammation  of  the  lungs,  by 
which  it  may  be  best  discriminated  from  the  tubercular  obstruc- 
tion :  it  exisfs  only  in  this  case  and  in  the  pulmonary  apoplexy. 
This  granular  appearance  becomes  still  more  obvious  when  we 
tear  asunder  a  portion  of  hepatized  lung.  In  this  case,  the  pul- 
monary substance  seems  to  consist  of  an  infinity  of  small  grains, 
round  or  ovoid,  very  equal  in  point  of  size,  and  of  the  different 
colors  already  mentioned.  These  are  evidently  the  air  cells 
converted  into  solid  grains  by  the  thickening  of  their  parietes 
and  the  obliteration  of  their  cavities  by  a  concrete  fluid.*  When 
a  lung  is  hepatized  throughout,  it  seems,  at  first  sight,  to  be 
more  voluminous  than  natural.  This  appearance  is,  however, 
deceptive,  and  is  occasioned  by  the  inability  of  the  lung  to  con- 
tract, on  the  chest  being  laid  open,  as  in  the  sound  state  of  the 
viscus.  I  have  frequently  measured  the  chest  in  cases  of 
pneumonia,  both  on  the  living  and  dead  body,  and  have  never 
been  able  to  discover  the  least  dilatation  of  the  affected  side  ; — a 
circumstance  which,  as  we  shall  see  hereafter,  constitutes  in  it- 
self a  marked  difference  between  the  signs  of  pneumonia  and 
pleurisy.  It  even  appears  that  the  inflamed  lung,  so  far  from 
being  able  to  overcome  the  resistance  opposed  by  the  solid  walls 

*  This  is  also  the  opinion  of  Andral,  who  considers  pneumonia  as  consisting 
essentially  in  inflammation  of  the  air  cells,  the  internal  surface  of  which  secretes 
at  first  amuco-sanguineous  and  then  a  purulent  fluid.  (Clin.  Med.  torn.  ii.  p.  312.) 
Andral's  opinion  is  greatly  corroborated  by  an  experiment  mentioned  by  M. 
Louis.  (Recherches  sur  la  Phthisie,  p.  9.)  He  says,  that  if  we  throw  an  injec- 
tion gently  into  the  bronchi,  we  find  the  lungs  marked  by  an  infinity  of  small 
masses,  which,  when  divided,  afford  precisely  the  granular  aspect  of  this  organ 
in  a  state  of  hepatization.  Although  inflammation  of  the  pulmonary  tissue  is 
generally  marked  by  the  granular  surface,  it  is  not  always  so,  as  is  supposed  by 
Laennec.  "  In  some  cases,"  says  Dr.  Williams,  (Cyc.  of  Prac.  Med.  vol.  iii.  p. 
410^,)  the  granular  appearance  is  entirely  absent.  This  uniform  non-granular 
solidification  of  the  lung,  describedby  Andral,  (Anat.  Path.  ii.  510,)  and  Chomel, 
(Diet,  de  Med.  t.  17,  p.  237,)  is  not  recognised  by  Laennec  ;  but  from  having 
seen'the  condition  observed  by  the  other  authors,  as  an  indubitable  result  of  in- 
flammation, I  do  not  hesitate  to  describe  it  as  a  variety  of  hepatization."  Dr. 
Williams  differs  also  from  the  eminent  authorities  above  named,  as  to  the  cause 
of  the  granular  appearance  when  it  does  exist.  "  Many  minute  examinations," 
he  says,  "  which  I  have  made  of  hepatized  lungs,  have  convinced  me  that  the 
granulations  contain  no  viscid  mucus,  nor  does  their  appearance  by  any  means 
confirm  the  opinion  of  Andral.  They  appear  rather  to  consist  simply  of  the 
little  bunches  of  vesicles,  (in  which,  according  to  Reisseissen,  each  minute  bron- 
chus terminates,)  whose  membranous  tunics  have  become  so  swelled  by  the  de- 
position of  a  soft  albuminous  matter  in  them,  as  well  as  from  the  increased  size 
of  their  blood-vessels,  that  their  cavities  are  obliterated."  (hoc.  Cit.  p.  410. )— 
Transl. 


PNEUMONIA. 


211 


of  the  chest,  cannot  resist  the  slightest  compressing  cause.  I 
once  saw  in  a  hepatized  lung  a  depression  more  than  a  line  in 
depth,  accurately  circumscribed,  and  exactly  like  a  dint  made 
by  a  hammer  on  a  piece  of  lead,  corresponding  to,  and  evidently 
occasioned  by,  a  spot  of  false  membrane  of  the  consistence  of 
boiled  white  of  egg.  In  this  case,  all  the  rest  of  the  substance 
of  the  lung  was  united  to  the  costal  pleura  by  an  organized  cel- 
lular tissue,  of  much  older  date  than  the  disease  of  which  the 
patient  died.* 

Third  degree  (purulent  infdtration.) — In  this  stage  the  sub- 
stance of  the  lung  has  the  same  degree  of  hardness  and  the  gra- 
nular appearance  above  described,  but  is  of  a  yellowish-pale  or 
straw  color.  At  first,  the  pus,  as  it  begins  to  form,  appears  in 
small  detached  yellow  points,  increasing  the  motley-colored 
shading  formerly  noticed.  These  points  gradually  combine,  and 
the  whole  lung  finally  assumes  a  uniform  straw,  or  lemon-yellow 
color,  and  when  incised  exudes,  in  greater  or  less  quantity,  a 
yellow,  opaque,  viscid  matter,  evidently  purulent,  but  much  less 
offensive  to  the  smell  than  the  pus  of  an  external  wound.  In 
this  state,  the  pulmonary  substance  is  much  more  humid  and 
softer  than  in  the  red  hepatization.  The  granulated  texture 
gradually  disappears  as  the  purulent  softening  advances :  and  even 
before  this  latter  stage  has  attained  its  acme,  the  parenchyma  of 
the  lungs  gives  way  beneath  the  fingers  like  a  soft  clot.  When 
the  lung  contains  much  black  pulmonary  matter,  as  is  very  com- 
monly the  case  in  adults  and  old  persons,  both  the  pus  and  the 
pulmonary  substance  assume  an  ash-grey  color,  which  has  been 
recently  denominated  by  some  writers  grey  hepatization.^  At 
other  times,  particularly  in  children  and  young  persons,  the  infil- 
trated pus  is  of  a  fine  whitish-yellow  color.  This  pus  when  first 
exhaled  is  concrete  or  plastic  like  the  false  membranes,  and  passes 
rapidly  through  different  degrees  of  softening  before  it  acquires 
its  proper  mucilaginous  consistence.  When  it  begins  to  soften, 
if  the  part  containing  it  is  pressed  or  scraped,  it  escapes  under 
the  form  of  a  greasy  matter,  which  a  superficial  observer  might 
mistake  for  fat,  but  which  is  in  reality  albumen.J     The  state  just 

*  M.  Broussais  says,  he  has  sometimes  seen  the  impression  of  the  ribs  on 
hepatized  lungs.     This  must  be  a  mistake.     The  tiling  is  impossible. — Author. 

M.  Broussais,  in  his  Examen,  published  in  1821,  (torn.  ii.  p.  718,)  re-asserts 
the  alleged  fact  of  the  impression  of  the  ribs  on  the  inflamed  lungs.  He  brings 
in  support  of  liis  assertion,  the  statements  of  Dr.  Pessyn,  who  says  he  saw  the 
same  appearance  on  the  lungs  of  a  man  who  died  of  an  ancient  pleurisy,  in  the 
year  1820.  Frank  makes  the  same  statement  as  Broussais,  De  cur.  Horn.  Morb. 
vol.  ii.  p.  130. —  Transl. 

t  This  term  which  is  incorrectly  applied  to  the  state  described  in  the  text, 
inasmuch  as  the  color  is  not  grey,  but  yellowish-greyish  or  ash-colored,  is  more- 
over improper,  being  applied  toother  morbid  conditions  of  the  lungs. — Author. 

t  Broussais  has  clearly  fallen  into  this  error.  (Doct.  Med.  torn.  ii.  p.  735.) — 
Author.  • 


212  PNEUMONIA. 

described  is,  strictly  speaking,  the  suppuration  of  the  pulmonary 
substance.  I  shall  presently  have  occasion  to  notice  those  rare 
cases  in  which  the  pus  is  collected  into  one  spot,  constituting 
abscess  of  the  lungs. 

The  three  degrees  of  inflammation  just  described  are  very 
commonly  re-united  in  various  ways.  Sometimes  one  lung  is 
inflamed  in  the  third  degree,  through  its  whole  extent,  while  the 
other  contains  only  some  portions  affected  in  the  first  or  second 
degree.  Frequently  the  three  degrees  are  found  in  the  same 
lung,  dividing  it  into  as  many  zones,  strongly  contrasted,  or  grad- 
ually and  insensibly  shading  one  into  another.  The  transition  of 
one  stage  into  another,  is  marked  by  the  occurrence  of  some 
points  of  the  more  advanced  degree  amidst  a  part  which  is  only 
affected  in  the  inferior  degree :  in  this  way,  the  transition  from 
the  first  to  the  second  stage  is  indicated  by  a  red  tissue,  con- 
taining much  frothy  and  bloody  serosity,  but  still  crepitous, 
intermixed  with  which  are  some  portions  of  a  redder  color, 
much  more  solid,  not  at  all  crepitous,  containing  less  fluid,  and 
granular  when  incised.  Sometimes  these  indurated  portions  are 
exactly  circumscribed  by  a  pulmonary  lobule :  and,  in  children 
more  especially,  we  sometimes  even  find  dispersed  in  the  centre 
of  the  lungs,  a  certain  number  of  lobules  arrived  at  the  stage  of 
hepatization,  while  those  immediately  surrounding  them  are  per- 
fectly sound.  This  variety  of  pneumonia  has  in  some  recent 
works  been  denominated  lobular.  In  these  cases  we  may  con- 
sider the  inflammation  as  having  commenced  in  several  distinct 
points  at  the  same  time,  and  being  interrupted  in  its  course  by 
the  treatment  or  some  other  cause,  has  not  extended  to  the  rest 
of  the  lung,  or,  having  extended  to  it  in  a  slight  degree,  has 
terminated  in  resolution  before  death.  We  may  convince  our- 
selves of  the  correctness  of  this  opinion  by  examining  different 
lungs  in  different  stages  of  resolution  from  inflammation.*  The 
transition   from  the  second  to  the  third  stage  is  marked  by  the 

*  M.  Andral  has  described  another  form  of  pneumonia  in  which  not  whole 
lobules,  but  fractions  of  lobules,  that  is,  certain  air  cells  only,  are  inflamed. 
This  vesicular  pneumonia  is  recognized  by  the  existence  of  red  granulations 
disseminated,  in  greater  or  less  numbers,  in  a  portion  of  pulmonary  tissue 
otherwise  healthy.  (Precis  d'Anat.  Path.  t.  ii.  p.  509.)  I  am  not  sure  "that  this 
form  of  disease  ought  to  be  recognized  as  a  variety  of  pneumonia.  I  have  my- 
self never  observed  these  isolated  red  granulations;  but  I  have  frequently  seen 
lungs,  which  were  otherwise  healthy,  appear,  on  being  incised,  as  if  they  were 
sprinkled  over  with  very  minute  ecchymosed  points,  resembling  flea-bites  on 
the  skin.     Is  this  the  first  stage  of  vesicular  pneumonia?— (M.  L.)t 

\  Since  the  publication  of  my  researches  on  this  subject,  I  have  had  many 
an  opportunity  of  examining  these  red  granulations,  the  existence  of  which  M. 
Meriadec  Laennec  is  inclined  to  doubt.  I  have  satisfied  myself  that  they  are  no 
other  than  partial  inflammations,  bearing  the  same  relation  to  the  pulmonary  lo- 
bules which  they  attach  only  at  a  few  points,  that  lobular  pneumonia  itself  bears  to 
the  inflammation  of  an  entire  lobe.  I  think  that  in  acute  bronchitis  with  fever, 
the  cases  of  vesicujar  pneumonia  are  far  from  uncommon—  Andral. 


PNEUMONIA.  213 

existence  of  yellowish,  irregular,  uncircumscribed  spots,  amid  a 
portion  of  lung  inflamed  in  the  second  degree,  the  one  color 
passing  insensibly  into  the  other.  It  is  this  state  of  lung  which, 
by  the  union  of  the  two  colors  mentioned  with  the  black  or  grey 
stripes  produced  by  the  black  pulmonary  matter,  presents  an  ap- 
pearance extremely  like  a  piece  of  granite  composed  of  red  and 
yellow  felspar,  grey  quartz,  and  black  mica. 

The  lower  part  of  the  lungs  are  those  most  commonly  occupied 
by  pneumonia  ;*  and  when  the  disease  involves  the  whole  viscus, 
it  is  almost  always  in  the  inferior  part  that  it  commences.  When 
the  three  degrees  of  inflammation  exist  in  different  parts  of  the 
same  lung,  the  site  of  the  more  advanced  stage  is  usually  in  the 
same  inferior  portion.  It  is  much  more  uncommon  to  find  the 
inflammation  confined  to  the  upper  lobe.  It  is  not  so  unusual, 
however,  to  find  a  part  of  the  centre  of  the  lung  inflamed,  while 
the  superficial  portion  is  in  a  sound  state.  We  never  find  the 
whole  of  both  lungs  inflamed  in  the  third  or  even  second 
degree  ;  and  this  for  obvious  reasons ;  since  an  obstruction  of 
this  kind  could  not  take  place  instantaneously,  and  must  render 
respiration  quite  impossible.  But  it  is  by  no  means  uncommon 
to  meet  with  cases  in  which  one  whole  lung  and  more  than  half 
the  other  are  quite  impervious  to  air.  On  the  other  hand,  we 
find  death  take  place  before  the  obstruction  has  reached  the 
fourth  part  of  the  organs  of  respiration ;  a  fact  which,  as  well  as 
many  others,  proves  that  death  is  frequently  occasioned  much 
more  by  the  exhaustion  of  the  vital  principle  than  by  the 
extent  or  intensity  of  the  organic  alteration.  The  right  lung 
is  more  frequently  affected  than  the  left,  not  only  in  cases  of 
pneumonia,  but  in  almost  all  the  other  morbid  affections  to  which 
these  organs  are  subject.  This  fact  has  been  long  noticed  by 
practitioners  and  medical  writers,  and  is  noticed  among  others  by 
Morgagni.f 

*  This  fact,  which  cannot  be  denied,  proves  how  very  inexact  is  the  opinion  of 
M.  Broussais,  that  tubercles  are  the  result  of  inflammations.  If  this  were  true, 
the  inferior  and  not  the  upper  lobes  ought  to  be  the  principal  site  of  these  bodies  ; 
but  the  reverse  is  well  known  to  be  the  truth. — Author. 

This  statement  of  our  author  seems  less  supported  by  some  of  our  best  pathol- 
ogists, than  might  have  been  expected.  Andral  says,  that  out  of  eighty-eight 
cases  of  pneumonia,  the  lower  lobe  was  affected  in  forty-seven,  the  upper  lobe 
in  thirty,  and  the  whole  lung  in  eleven  cases;  (Op.  Cit.  p.  317;)  and  Chomel 
informs  us,  (Diet,  de  Med.  t.  xvii.  p.  209,)  that  in  fifty-nine  cases,  the  upper 
lobes  were  affected  in  thirteen,  the  lower  in  eleven,  the  whole  of  one  lung  in 
thirty-one,  the  posterior  parts  in  two,  and  the  middle  in  one.  M.  Broussais  says, 
(Examen.  torn.  ii.  p.  720.)  that  since  the  publication  of  M.  Laennec's  work,  his 
(M.  B.'t)  pupils  have,  very  often  shown  him  cases  of  hepatization  of  the  upper 
lobe,  with  the  view  oT  pointing  out  Laennec's  mistake.  Frank  states  his  expe- 
rience to  be  the  reverse  of  Laennec's  : — "  Frequentius  forte  supejiores  pulmo- 
niim  lobos  inflanmiatos  deteximus."  (De  Cur.  Horn.  Morb.  torn.  ii.  p.  132.) 
He  says  also,  that  he  has  not  found  the  right  lung  more  frequently  affected  than 
the  left. —  Transl. 

t  This  is  strikingly  shown  by  the  following  statements: — M.  Andral  says, 


214  PNEUMONIA. 

Abscess  and  partial  inflammation  of  the  lungs. — The  species 
of  suppuration  above  described  is  the  only  one  of  common  occur- 
rence in  the  lungs ;  for  notwithstanding  the  opinion  of  the  an- 
cients, and  the  common  notions  of  mere  practical  physicians  of 
the  present  day,  respecting  pulmonary  abscesses,  which  are 
usually  termed  vomica,  it  is  certain  that  there  is  no  organic 
lesion  more  uncommon  than  a  real  collection  of  pus  in  the  sub- 
stance of  the  lungs.  The  vomica  of  Hippocrates  and  our  com- 
mon practitioners  is,  as  we  shall  see  hereafter,  the  result  of  the 
softening  of  a  large  mass  of  tuberculous  matter.  Among  several 
hundred  dissections  of  pneumonic  subjects,  which  I  have  made  in 
a  period  of  more  than  twenty  years,  I  have  not  met  with  a  col- 
lection of  pus,  in  an  inflamed  lung,  more  than  five  or  six  times. 
These  were  not  of  large  extent,  nor  numerous  in  the  same  lung. 
They  were  dispersed  in  different  parts  of  the  lungs,  which  were 
in  the  third  degree  of  inflammation  above  described.  The  walls 
of  these  abscesses  were  formed  by  the  pulmonary  tissue,  infil- 
trated with  pus,  and  in  a  state  of  soft  disorganization,  which 
gradually  decreased  as  we  receded  from  the  centre  of  the  col- 
lection. When  we  forcibly  drag  from  the  cavity  of  the  chest  an 
inflamed  lung  attached  to  the  costal  pleura  by  old  cellular  ad- 
hesions, it  frequently  happens  that  the  parts  most  infiltrated  with 
pus  give  way  under  the  fingers,  or,  without  suffering  any  exter- 
nal wound,  yield  internally  under  the  pressure  so  as  to  form  a 
soft  sanious  mass,  which  an  inattentive  observer  might  mistake 
for  a  collection  of  pus  :*  if  cases  of  this  kind  were  received  as 
instances  of  pulmonary  abscess,  nothing  would  be  more  common .f 

(Cl.  Med.  t.  ii.  p.  317.)  that  out  of  two  hundred  and  four  cases  of  well-marked 
pneumonia,  the  right  lung  was  affected  in  one  hundred  and  twenty-one,  the  left 
lung  in  fifty-eight,  and  both  lungs  in  twenty-five.  M.  Chomcl  says,  (Diet,  de 
Med.  t.  xvii.  p.  508,)  that  in  fifty-nine  dissections  he  found  the  right  lung  affected 
in  twenty-eight,  the  left  in  fifteen,  and  both  in  sixteen:  and  he  adds,  that  in 
the  instances  where  both  lungs  were  affected,  the  right  was  generally  most  so  : 
and  that  the  results  afforded  by  the  cases  of  recovery  were  precisely  of  the  same 
kind.  Autenrieth  {Physiologic,  §  1045)  says,  that  the  right  side  is  most  obnox- 
ious to  acute,  and  the  left  to  chronic  diseases.  A  more  recent  statement  by  M. 
Lombard,  and  on  a  still  larger  scale,  strongly  supports  the  same  view  of  the 
case.  He  found  that  of  868  cases  of  pneumonia,  413  were  on  the  right  side, 
260  on  the  left  side,  and  195  on  both  sides.  (Arrhiv.  Gen.  de  Med.)  The  gen- 
eral result  of  these  united  statements  is,  that  out  of  a  total  of  1131  cases,  the 
right  side  was  affected  in  562,  the  left  in  333,  and  both  in  236.  Taking  these 
results  in  round  numbers,  and  approximative^,  and  assuming  them  to  give  a 
fair  view  of  the  general  habitudes  of  the  disease,  we  would  say,  that  out  of  every 
ten  cases  of  pneumonia,  we  might  expect  five,  or  one-half,  to  be  confined  to  the 
right  side ;  three  to  the  left ;  and  two  to  extend  to  both.—  Transl. 

*  Speaking  of  this  condition  of  lung,  Andral  says,  (Clin.  Med.  torn.  ii.  jp.  310.) 
"  Compressed  between  the  fingers,  it  falls  into  a  greyish  pu^p,  which  only  differs 
from  the  infiltrated  pus  by  being  a  little  thicker.  Owing  to  this  great  friability, 
if  we  force  our  fingers  into  any  part  of  the  lung,  the  cavity  thus  artificially 
formed  is  immediately  filled  with  pus,  and  might  be  mistaken  for  an  abscess."— 
Transl. 

t  It  is,  no  doubt,  this  circumstance  which  has  induced  M.  Andral  (Clin.  Med. 


PNEUMONIA. 


215 


Once  only,  during  the  space  of  time  above  mentioned,  have  I 
seen  a  collection  of  pus  in  the  lungs,  of  considerable  extent. 
This  was  situated  in  the  middle  of  the  lung  anteriorly,  was  flat  and 
elongated,  and  would  have  contained  three  fingers.  The  walls  of 
this  abscess  had,  properly  speaking,  no  surface,  the  pus  being  ob- 
served gradually  to  pass  into  a  purulent  detritus,  and  this  into  a 
firmer  tissue,  still  loaded  with  pus,  as  we  receded  from  the  centre 
of  the  collection  :  and  at  length,  about  half  an  inch  from  the  mat- 
ter, the  purulent  infiltration  was  not  greater  than  it  usually  is  in 
the  third  stage  of  pulmonary  inflammation.  In  this  case,  as  in  all 
the  rest  where  abscess  was  found,  the  inflammation  occupied  only 
a  part  of  one  lung.  This  circumstance  may  help  to  account  for 
the  infrequency  of  collections  of  pus  in  the  lungs,  as  cases  of  par- 
tial peripneumony  usually  yield  either  to  nature  or  art,  while  an 
affection  of  great  extent  produces  death  before  the  purulent  infil- 
tration is  so  far  advanced  as  to  form,  by  the  destruction  of  the  tis- 
sue containing  it,  distinct  collections  of  pus.* 

An  English  physician,  Sir  Alexander  Crichton,  has  accused 
me  of  representing  the  occurrence  of  pulmonary  abscess  as  much 
too  rare.  He  considers  this  as  taking  place  in  more  than  half 
the  cases  of  pneumonia,  which  have  been  badly  treated.  Pro- 
fessor Himly,  of  Goettingen,  has  made  the  same  remark.  If  the 
opinion  of  these  physicians  is  founded  merely  on  the  observation 
of  symptoms  during  life,  and  this  seems  the  case  with  Sir  A. 
Crichton  at  least,  it  is  evident  that  it  can  have  no  weight  in  de- 
ciding the  question,  purely  anatomical,  how  under  consideration. 
If,  on  the  contrary,  their  statement  reposes  on  morbid  dissections, 
we  must  conclude  either  that  cases  of  partial  peripneumony  are 
more  frequent  in  the  north  of  Europe,  or  that  the  observations 
of  these  authors  have  been  made  during  a  medical  constitution 
when  they  were  particularly  prevalent.     I  have  myself  recently 

torn,  ii.)  to  propose  to  substitute  for  hepatization  and  suppuration  the  terms  red 
softening  and  grey  softening.  But  in  the  red  hepatization,  there  is  really  indu- 
ration, although  the  pulmonary  substance  is  more  humid  than  natural.  The 
same  is  true  of  the  purulent  infiltration,  so  long,  at  least,  as  it  is  not  converted 
into  abscess.  To  express  M.  Andral's  ideas,  the  terms  increase  of  humidity 
would  have  been  more  appropriate. — Author. 

*  The  testimony  of  Broussais  on  this  point  is  very  strong.  He  says,  (Hist, 
des  Phleg.  Chron.  torn.  ii.  p.  111.)  "  If  ulceration  of  the  lungs  without  tubercles 
were  common,  we  should  meet  with  it  in  the  military  service  more  frequently 
than  any  where  else,  since,  during  winter,  in  climates  only  moderately  cold, 
there  is  not  one  patient  out  of  fifty  in  the  hospitals,  in  whom  the  lungs  are  not 
more  or  less  inflamed,  and  very  few  of  these  in  whom,  on  examination  after 
death,  the  lungs  are  not  found  indurated.  Now,  although  I  have  never  once 
omitted  to  examine,  I  never  met  with  a  case  of  ulceration  without  tubercles  but 
once ;"  and  in  this  case  the  inflammation  was  produced  by  a  musket  ball  lodged 
in  the  lungs  for  six  years.  It  is  hardly  necessary  to  observe  how  very  different 
are  the  opinions  of  English  writers  respecting  the  frequency  of  pulmonary  ab- 
scesa.  (See  Bail  lie,  Morb.  Anat.  p.  70.)  I  believe  they  are  wrong — misled  (as  I 
myself  have  been)  by  imperfect  examination. —  Transl. 


216  PNEUMONIA. 

witnessed  one  of  this  kind.  In  the  course  of  the  year  1823,  I 
met  with  more  than  twenty  cases  of  partial  peripneumony  which 
terminated  in  abscess.  All  these  patients  afforded  distinct  pec- 
toriloquy and  an  evident  cavernous  rhonchus  in  the  place  of  the 
excavation ;  and  from  these  and  other  signs  to  be  noticed  shortly, 
although  I  had  an  opportunity  of  proving  my  diagnosis  by  dis- 
section in  two  cases  only,  the  rest  being  all  cured,  I  could  affirm 
the  existence  of  abscess  in  the  others  with  equal  certainty.  Some 
of  these  abscesses  were  evidently  of  considerable  extent,  and  yet 
perfect  cicatrization  took  place  within  a  period  of  from  fifteen  to 
forty  days.  In  one  patient  who  yielded  pectoriloquy  and  the 
cavernous  rhonchus  over  a  space  of  three  square  inches,  on  the 
lower  part  of  the  right  back,  three  months  elapsed  before  these 
signs  completely  disappeared  ;  and  in  another  case,  where  a  much 
smaller  abscess  existed  in  the  top  of  the  left  lung,  they  did  not 
entirely  disappear  until  after  six  months :  previously,  however,  to 
this  event,  both  these  patients  had  long  recovered  their  flesh  and 
strength,  and  considered  themselves  as  completely  cured.* 

One  of  the  best  proofs  which  I  can  give  of  the  rarity  of  ab- 
scess of  the  lungs,  is  derived  from  this  fact,  that  notwithstanding 
the  zeal  with  which  morbid  anatomy  has  been  cultivated  in 
France  during  the  last  twenty  years,  I  know  of  only  two  well- 
authenticated  instances  of  this  affection,  besides  those  above- 
mentioned.  In  a  preparation  presented  by  Dr.  Honore  to  the 
Royal  Academy  of  Medicine,  in  1823,  there  existed  in  the  centre 
of  a  hepatized  lobe,  an  excavation  filled  with  pus  and  capable  of 
containing  a  middle-sized  apple.  The  patient  had  died  of  an 
acute  pneumonia.  The  other  instance  is  given  by  M.  Andral, 
and  occurred  in  the  case  of  a  man  who  died  on  the  nineteenth 
day  of  the  disease.  The  middle  and  lower  lobes  on  the  right 
side  were  in  a  state  of  purulent  infiltration,  and  "  towards  the 
middle  of  the  lower  lobe,  the  tissue  was  found  degenerated  into 
a  kind  of  paste,  in  the  centre  of  which  there  was  found  pure  pus. 
The  substance  of  the  lung  surrounding  this,  gradually  assumed 
more  firmness  in  receding  from  the  abscess."  (Clin.  Med.  torn, 
ii.  p.  313.)f 

*  It  is  singular,  after  having  so  justly  remarked  that  the  opinions  of  Himly  and 
Grichton  would  be  inadmissible  if  founded  merely  on  symptoms  observed  durincr 
life,  that  Laennec  should  have  so  immediately  fallen  into  a  similar  train  of  rea- 
soning. The  stethoscopic  signs,  no  doubt,  deserve  more  confidence  than  the 
varying  symptoms  which  depend  on  mere  disorder  of  function  ;  but  it  is  no  less 
obvious  that  they  cannot  be  received  as  decisive  evidence  of  a  question  purely 
anatomical.  Moreover,  in  the  greater  number  of  the  cases  referred  hi.  the  exist- 
ence of  distinct  pectoriloquy  and  distinct  cavernous  rhonchus,  was  not  merely  con- 
testible,  but  was  actually  contested.  Andral  was,  therefore,  justified  in  asM-rt- 
ing,  (Precis  d'Jlnat.  Path.  t.  ii.  p.  535,)  that  Laennec  was  in  this  case  deceived  by 
auscultation. — (M.  L.)  I  entirely  concur  in  the  opinions  advanced  in  this  note. 
—  Transl. 

t  The  infrequency  of  pulmonary  abscess  is  confirmed  by  the  testimony  of  M. 


PNEUMONIA. 


217 


From  the  description  just  given  of  these  purulent  collections, 
it  will  be  readily  perceived  how  much  they  differ  from  those 
produced  by  softening  of  tuberculous  matter.  In  these  last, 
although  the  color  and  appearance  of  the  tuberculous  matter 
are,  in  some  cases,  pretty  much  like  those  of  pus,  they  generally 
differ  in  containing  tuberculous  fragments  of  a  friable  consist- 
ence. Besides  the  exact  circumscription  of  the  excavations,  the 
solidity  of  their  walls,  the  soft  false  membrane  with  which  these 
are  constantly  lined,  and  the  semi-cartilaginous  membrane  which 
occasionally  succeeds  to  this,  suffice  to  discriminate  these  from 
the  purulent  collections  above  described  ;  independently  of  the 
difference  of  the  stethoscopic  signs,  which  characterize  them  re- 
spectively in  the  living  body.* 

Notwithstanding  what  I  have  stated  of  the  great  infrequency 
— and  almost  impossibility — of  the  formation  of  a  great  abscess 
of  the  lungs,  the  thing  appears  to  occur  in  rare  instances. 
Twice  or  thrice  I  have  met  with  enormous  excavations  occupy- 
ing nearly  the  whole  of  one  lung,  and  which  did  not  seem  to 
originate  in  softened  tubercles.  Among  others  I  may  mention 
the  case  of  a  young  man  in  the  Necker  Hospital,  in  1822,  who 
had  in  the  inferior  and  middle  parts  of  the  right  lung,  a  cavity 
capable  of  containing  a  pint  and  a  half  of  fluid.  The  outer 
boundary  of  this  cavity  was  entirely  destroyed  over  a  space  of 

Chomcl,  who  states,  that  during  a  period  of  seventeen  years,  he  had  only  twice 
met  with  unequivocal  examples  of  it,  if  indeed  so  often.  {Diet,  de,  Med.  t.  xvii.  p. 
239.)  Since  the  publication  of  the  first  edition  of  the  Clinique  Medicate,  M.  An- 
dral  has  twice  observed,  in  the  lungs  of  new-born  infants,  abscesses  bearing  no  re- 
semblance to  tuberculous  vomicae.  In  one  of  these  cases  the  abscesses  were  nume- 
rous and  large.  (Clin.' Med.  2nd.  Ed.  t.  i.  p.  507;  Precis,  d'jinat.  Path.t.  ii.  p. 
535. )  Perhaps  collections  of  pus  are  more  common  in  the  lungs  of  infants, 
which  arc  naturally  very  compact,  than  in  those  of  adults. — (M.  L.) 

*  There  is  a  peculiar  morbid  condition,  in  which  it  is  not  uncommon  to  find 
purulent  collections  profusely  disseminated  through  the  substance  of  the  lungs 
— namely,  when  inflammation  of  the  veins  occurs,  and  the  pus  formed  in  these 
vessels  passes  with  the  blood  through  all  the  organs,  and  collects  in  many  of 
them  in  the  form  of  abscesses,  commonly  small,  but  numerous.  It  is  in  the 
lungs  that  we  most  often  find  these  abscesses,  which  are  for  the  most  part, 
separated  from  one  another  by  sound  tissue. 
m  We  must  not,  however,  always  expect  to  find  phlebitis  when  we  discover 
these  purulent  collections.  Deposits  of  this  kind  are  met  with  when  no  sign  of 
venous  inflammation  can  be  discovered,  and  if  phlebitis  be  admitted,  it  must  be 
by  supposition.  In  this  relation  I  have  cited  in  my  Clinique  Medicale,  3d  edit, 
vol.  i.,  a  fatal  case  of  confluent  small  pox,  in  which  the  right  lung  was  found 
riddled  as  it  were,  with  minute  abscesses,  the  size  of  which  varied  from  that  of 
a  filbert  to  that  of  a  small  pea.  Some  of  them  were  surrounded  by  perfectly 
healthy  lung;  around  others  the  pulmonary  tissue  was  hepatized.  At  some 
point-;  were  found,  instead  of  abscesses,  small,  hard  greyish  masses,  which  were, 
evidently,  portions  of  the  pulmonary  tissue  infiltrated  withjius.  All  the  veins 
superficial  and  deepseated,  of  the  trunk,  limbs  and  neck  were  examined  with 
care,  hut  presented  nothing  remarkable;  nothing  abnormal  was  found  in  the 
arteries,  lymphatic  vessels,  or  ganglions.  Pus  had  filtered  into  the  muscles  of 
the  neck  and  between  the  oesophagus  and  vertebral  column  ;  but  in  other  parts 
there  was  none  to  be  seen. — Andral. 

28 


218  PNEUMONIA. 

more  than  six  square  inches,  and  was  replaced  by  the  costal 
pleura,  which  adhered  closely  to  the  lips  of  the  excavation. 
Seven  or  eight  bronchial  tubes  opened  into  this  cavity,  which 
was  lined  by  a  strong  false  membrane,  and  contained  only  a 
bloody  serosity.  This  lung  contained  no  tubercles.  .  Both  metal- 
lic tinkling  and  Hippocratic  fluctuation  were  observable,  during 
life,  in  this  excavation.* 

Resolution  of  pneumonia. — When  resolution  takes  place,  be- 
fore the  inflammation  has  reached  the  second  stage,  the  effused 
blood  is  absorbed,  and  the  pulmonary  tissue  appears  as  dry  as  in 
the  sound  state,  only  red  as  if  dyed  ;  occasionally  a  serous  suc- 
ceeds the  sanguineous  infiltration.  When  the  inflammation  has 
reached  the  second  stage,  or  hepatization,  resolution  then  pre- 
sents the  following  characters :  the  indurated  parts  become  pale, 
passing  from  red  or  violet — first  to  violet-gray,  then  to  a  reddish 
flaxen  gray,  and  finally  to  a  pale  reddish,  the  natural  color  of 
the  lungs  ;  they,  however  frequently  retain  a  reddish  shade  for 
some  time  after  they  have  become  permeable  to  the  air.  While 
these  changes  of  color  are  taking  place,  the  texture  of  the  part 
becomes  softer,  more  humid,  and,  when  cut,  exudes  more  serum 
than  blood.  This  serum  is,  at  first,  intermixed  with  some  very 
small  air  bubbles,  and  gradually  becomes  more  frothy.  The 
granular  aspect  of  the  part  disappears,  and  the  cellular  vesicular 
character  returns.  At  last  the  pulmonary  tissue  resumes  its 
natural  dryness  and  color,  but  for  some  time  still  remains  firmer, 
more  elastic,  and  heavier,  owing,  no  doubt,  to  a  remaining  thick- 
ening of  the  walls  of  the  air  cells.  It  is  unusual  for  resolution  to 
proceed  equally  in  the  whole  inflamed  parts.  Some  harder  spots 
are  found  here  and  there,  retaining  the  characters  of  hepatiza- 
tion in  their  centre,  while  their  circumference  gradually  passes 
through  the  lesser  degree  into  the  sound  texture  of  the  organ. 
Frequently,  also,  we  can  perceive  on  the  surface  of  our  incisions, 
a  slight  violet  or  reddish  patch,  as  if  made  by  the  stroke  of  a 
pencil,  pointing  out  the  site  of  the  inflammation,  after  the  part 
had  been  completely  restored  to  its  functions. 

Even  when  it  has  reached  the  third  stage,  or  that  of  purulent* 
infiltration,  peripneumony  may  still  terminate  in  resolution  by 
the  absorption  of  the  pus,  and  without  disorganization  of  the 
pulmonary  substance.  At  the  commencement  of  this  resolution, 
the  yellow  or  ash  yellow  color  of  the  part  becomes  paler  and 
whiter.  The  pus  contained  in  it  is  intermixed  with  serum  ;  and 
this  in  a  short  time  is  intermixed  with  small  air-bubbles  ;  and 
shortly  after,  the  pus  is  so  much  reduced  in  quantity  as  to  show 

*  Was  not  this  excavation  rather  the  consequence  of  an  apoplectic  affection 
than  of  a  true  abscess  of  the  pulmonary  substance  ?  I  am  led  to  think  so  from 
the  bloody  serosity  contained  in  it.— (M.  L.) 


PNEUMONIA.  219 

itself  merely  under  the  form  of  small  specks.  The  cellular  and 
vesicular  aspect  of  the  viscus  re-appears ;  it  loses  its  hepatic 
firmness,  and  has  now  only  the  solidity  possessed  by  the  first 
degree  of  pneumonia  or  oedema  ;  it  is  slightly  crepitous,  and  does 
not  always  sink  in  water ;  but  when  incised  the  surfaces  are  still 
of  a  dirty  yellowish  or  green  color,  very  different  from  the  sound 
lung.  If  resolution  is  far  advanced,  this  color  is  the  only  morbid 
appearance  left,  except  a  slight  serous  infiltration,  which  is  also 
eventually  absorbed. 

Previously  to  my  use  of  emetic  tartar  in  large  doses,  I  had  oc- 
casion to  witness  this  resolution  of  pulmonary  inflammation  in  a 
very  small  number  of  cases.  Since  I  have  adopted  this  practice, 
I  have  lost  no  patients  affected  with  pneumonia,  except  sueh  as* 
were  attacked  by  it  in  the  course  of  other  severe  diseases  ;  and 
even  in  cases  of  this  kirW,  the  resolution  of  the  pneumonic  affection 
was,  in  almost  all  of  them,  more  or  less  advanced,  at  the  period  of 
death.  The  most  interesting  examples  of  this  kind  were  afforded 
by  persons  laboring  under  diseases  of  the  heart ;  or  they  occurred 
in  old  subjects  who  had  long  labored  under  various  chronic  dis- 
eases. When  I  employed  in  my  practice  only  blood-letting  and 
derivatives,  I  was  accustomed  to  see  my  patients  die  in  the  first 
days  of  the  disease,  and  1  always  found  the  lungs  affected  with 
the  inflammatory  engorgement,  or  the  hepatic  induration^,  red  or 
yellow.  At  present,  the  very  small  number  who  die  under  the 
use  of  the  emetic  tartar,  evidently  fall  victims  to  the  concomitant 
disease,  and  not  to  the  pneumonia,  since  I  almost  always  find  this 
in  the  progress  of  resolution. 

Duration  of  pneumonia,  and  of  its  different  stages. — Acute 
pneumonia  is  one  of  those  diseases,  which,  from  the  rapidity  and 
brevity  of  their  course,  and  the  shortness  of  the  period  in  which 
treatment  can  be  beneficially  applied,  demand  the  utmost  atten- 
tion and  vigilance  on  the  part  of  the  physician.  Its  general  du- 
ration, however,  as  well  as  that  of  each  of  its  stages,  is  variable. 
I  have  several  times  seen  the  engorgement  (or  first  degree)  con- 
tinue for  seven  or  eight  days,  and  affect  the  whole  lung  and  part 
of  the  other,  and  prove  fatal  before  the  occurrence  of  any  very 
distinct  hepatization.  This  result  was  very  common  in  the  epi- 
demic of  1803-4,  (known  by  the  name  of  grippe,)  and  occurred 
equally  in  cases  where  bleeding  had  been  largely  used,  and  where 
it  had  not  teen  used  at  all.  Two  examples  of  the  same  kind 
are  recorded  by  M.  Andral  (Clin.  Med.  torn.  ii.  obs.  viii.  et  ix. 
p.  112.  115.)  In  other  cases,  on  the  contrary,  particularly  when 
the  disease  has  attacked  debilitated  or  very  old-  subjects,  or  su- 
pervened in  the»course  of  another  severe  malady,  the  inflamma- 
tion reaches  the  stages  of  purulent  infiltration  in  the  short  space 
of  thirty-six  or  even  twenty-four  hours.     With  the  exceptions 


220  PNEUMONIA. 

just  stated,  I  think  we  may  fix  the  duration  of  the  different 
stages  of  pneumonia  as  follows :  the  obstruction  or  first  stage 
usually  lasts  from  twelve  hours  to  three  days,  before  passing  to 
the  state  of  complete  hepatization ;  this  lasts  from  one  to  three 
days  before  spots  of  purulent  infiltration  make  their  appearance ; 
and  the  period  of  suppuration  (from  the  time  when  the  concrete 
purulent  infiltration  is  distinctly  perceptible,  until  this  is  com- 
pletely softened  to  a  viscid  fluid)  varies  from  two  to  six  days. 
Blood-letting,  derivatives,  and  resolvents  or  stimulants  of  the 
absorbent  system,  obviously  retard  the  progress  of  the  disease, 
and  consequently  prolong  the  period  of  the  first  two  stages. 
Convalescence  is  rapid  in  proportion  as  the  inflammation  is  of 
small  extent,  and  has  been  early  checked. 

State  of  the  bronchi. — The  lining  membrane  of  the  bronchi  is 
commonly  very  red  in  the  portions  of  the*lung  affected  by  the  in- 
flammation ;  it  is  also  occasionally  swollen,  and  sometimes  the 
redness  extends  over  the  whole  bronchi,  but  both  these  cases  are 
uncommon.  In  the  stage  of  purulent  infiltration,  the  membrane 
is  sometimes  pale,  and  sometimes  entirely  red  or  violet-colored, 
and  in  both  these  cases  it  appears  to  be  softened. 

Sect.  II.  Signs  and  symptoms  of  pneumonia. 

•  t 

This  is  one  of  the  diseases  most  anciently  known  ;  and  before 
pathological  anatomy  (which  has  been  prosecuted  with  zeal  in 
every  part  of  Europe  since  the  time  of  Morgagni)  had  investi- 
gated the  true  nature  of  diseases,  it  was  generally  regarded  as 
one  of  the  internal  affections  most  readily  recognized.  This, 
however,  is  far  from  being  the  case.  It  is  not  easily  recognized 
except  when  it  is  uncomplicated,  and  has  already  attained  a 
considerable  degree  of  intensity.  When  complicated  with  an- 
other disease,  and  also  in  its  very  commencement,  it  remains 
latent,  because  its  most  usual  symptoms  are  either  frequently 
wanting,  or  are  common  to  other  diseases. 

In  the  present  section,  I  shall-  first  notice  the  physical  signs 
which  characterise  the  disease  in  all  cases,  and  from  its  very  on- 
set ;  I  shall  then  speak  of  the  symptoms  depending  on  the  disor- 
der of  the  functions  of  the  lungs,  and  examine  how  far,  and  in 
what  cases  these  may  serve  as  signs ;  and,  finally,  I  shall  describe 
the  general  symptoms  and  the  progress  of  the  disease. 

Physical  signs. — The  crepitous  rhonchus  is  the  pathognomo- 
nic sign  of  the  first  stage  of  peripneumony.  It  is  perceptible 
from  the  very  invasion  of  the  inflammation :  at  this  time  it  con- 
veys the  notion  of  very  small  equal-sized  bubbles,  and  seems 
hardly  to  possess  the  character  of  humidity.  These  characters 
are  more  marked,  according  as  the  inflamed  spot  is  near  the  sur- 


PNEUMONIA.  221 

face  of  the  lungs.  The  sound  of  respiration  is  still  heard  dis- 
tinctly, combined  with  the  crepitous  rhonchus  ;  and  percussion 
affords  the  natural  resonance.  The  extent  over  which  the  ste- 
thoscope detects  the  rhonchus,  indicates  the  extent  of  the  inflam- 
mation. This  is  frequently  hardly  greater  than  the  diameter  of 
the  instrument.  The  further  we  remove  the  cylinder  from  the 
point  affected,  the  rhonchus  becomes  more  obscure,  and  ceases  to 
be  heard  altogether  at  the  distance  of  two  or  three  inches.  In 
proportion  as  the  obstruction  increases  and  verges  towards  hepa- 
tization, the  rhonchus  becomes  moister,  and  its  bubbles  more 
unequal  and  less  numerous  :  the  sound  of  respiration,  which  ac- 
companied it  at  first,  gradually  disappears :  and  at  last,  as  hepa- 
tization takes  place,  the  rhonchus  itself  ceases  to  be  heard.*  At 
this  period  of  the  disease,  the  sound  on  percussion  does  not  sen- 
sibly differ  from  that  of  health,  unless  the  obstruction  is  very  ex- 
tensive, and  already  verging  on  hepatization.  In  this  latter  case, 
it  becomes  somewhat  more  obscure.  But  when  the  obstruction 
is  confined  to  a  small  portion  of  the  lung,  or  when  it  exists  in 
the  form  of  isolated  masses  here  and  there,  percussion  affords  no 
information.  This  is  also  frequently  the  case,  even  in  an  exten- 
sive engorgement  of  the  lower  part  of  the  right  lung,  on  account 
of  the  natural  obscurity  of  the  sound  in  that  region  from  the 
presence  of  the  liver. 

Such  are  the  physical  signs  of  pneumonia  in  the  first  degree. 
Of  these  the  most  important  is  unquestionably  the  crepitous 
rhonchus  ;  inasmuch  as  it  is  invariably  present,  and  from  the  very 
invasion  of  the  disease ;  and  exists  in  no  other  case,  except  in 
oedema  of  the  lungs  and  pulmonary  apoplexy,  two  diseases  which 
are  easily  distinguished  from  this  by  their  own  peculiar  signs  and 
symptoms.  M.  Andral  is  mistaken  in  saying  that  the  crepitous 
rhonchus  sometimes  exists  in  simple  acute  bronchitis;  (CI.  Med. 
torh\  ii.  p.  333  ;)  and  I  think  this  is  evident  from  his  own  cases. 
From  its  constant  presence  in  this  disease,  I  regard  it  as  the  most 
practically  useful  of  all  the  stethoscopic  signs,  inasmuch  as  it 
points  out,  in  its  very  earliest  stage,  one  of  the  most  severe  and 
most  common  diseases,  and  thereby  enables  the  physician  to  ap- 

*  Andral  (Op.  Cit.  p.  312.)  considers  the  crepitous  rhonchus  as  produced  by 
tlie  intermixture  of  the  air  and  liquid  secretion  of  the  air-colls,  in  the  same 
manner  as  the  mucous  rhonchus  is  produced  in  the  bronchi.  The  following  is 
the  explanation  of  Dr.  Williams  : — "  The  distended  vessels,  and  the  serous  effu- 
sion in  the  insterstices,  press  on  the  minutest  bronchial  ramifications,  and  par- 
tially obstruct  the  ingress  of  air  into  the  cells  to  which  they  lead ;  whilst  the 
viscid  secretion  of  the  mucous  membrane,  simultaneously  inflamed,  filling  the 
calibre  of  the  tubes  thus  narrowed,  only  yields  to  the  air  in  respiration,  forcing 
its  way  through  it  in  successive  bubbles.  This  bubbling  passage  of  air  through 
a  viscid  liquid,  contained  in  an  infinity  of  tubes,  of  equally  diminished  calibre, 
cafises  that  regular  and  equable  crepitation  which  constitutes  the  true  rhonchus 
crepitans." — Rat.  Exp.  p.  81. —  Transl. 


222  PNEUMONIA. 

ply  his  means  with  much  more  chance  of  success  than  he  could 
have  done  even  a  few  hours  later.* 

When  the  inflammation  has  reached  the  degree  of  hepatiza- 
tion, wc  no  longer  perceive  in  the  affected  part,  either  the  crcpi- 
tous  rhonchus  or  the  respiratory  sound  ;  and  the  absence  of  these 
phenomena  is  frequently  the  only  sign  we  have  of  hepatization 
having  taken  place.  Bronchophony  exists  in  certain  cases,  par- 
ticularly if  the  inflammation  is  seated  near  the  roots  of  the  lungs, 
or  in  the  upper  lobes,  in  which  places  the  bronchial  tubes  are 
largest.  When  the  pneumonia  is  central,  bronchophony  either 
does  not  exist  at  all,  or  is  very  obscure ;  it  becomes  more  and 
more  manifest,  as  the  inflammation  approaches  flie  surface  of  the 
lungs.  By  means  of  this  sign,  I  have  frequently  been  able  to 
indicate,  previously  to  opening  the  chest,  the  precise  point  where 
a  central  peripneumony  had  reached  the  exterior  of  the  organ. 
This  is  easily  accounted  for  by  the  fact,  that  a  hepatized  lung 
is  a  better  conductor  of  sound  than  a  healthy  one, — broncho- 
phony being  nothing  more  than  the  resonance  of  the  voice  within 
the  bronchi  of  the  inflamed  part.  A  pleuritic  effusion,  if  oc- 
curring subsequently  to  the  hepatization,  renders  bronchophony 
stronger,  by  compressing  and  condensing  the  superficial  parts  of 
the  lungs  not  yet  affected  by  the  inflammation  ;  but  the  reverse 
happens  when  the  pleurisy  precedes  the  pneumonia.     It  is  more 

*  M.  Cruveilhier  regards  the  crepitous  rhonchus  as  a  sign  of  no  value  in  pneu- 
monia, in  comparison  with  those  of  bronchophony  and  tubary  respiration. 
This  opinion  is  tantamount  to  saying,  that  he  only  then  yields  confidence  to 
the  results  of  auscultation  when  the  disease  has  advanced  so  far  that  the  exis- 
tence is  self-evident.  M.  Chomel  also  asserts  (Diet,  de  Med.  t.  xvii.  p.  2o2) 
that  this  sign  may  be  wanting  in  pneumonia,  and  be  present  in  cases  wiiere 
the  existence  of  inflammation  is  extremely  doubtful.  The  doubts  of  men  so 
eminent  as  Andral,  Chomel,  and  Cruveilhier,  demand  from  us  some  investiga- 
tion whether  there  may  not  exist  certain  circumstances  calculated  to  produce 
mistake  respecting  the  value  of  the  crepitous  rhonchus.  In  the  first  place,  it 
is  possible  that  the  obscure  mucous  rhonchus  may  be  mistaken  for  it.  the  more  so 
because  the  two  are  nearly  allied  both  in  their  cause  and  character,  and  are,  in 
truth,  not  easily  discriminated  by  the  most  experienced.  Secondly,  the  crepitous 
rhonchus  may  have  been  really  heard  during  life,  and  yet  no  trace  of  inflammation 
be  found  after  death,  because  this  lias  taken  place  during  the  stage  of  resolution 
of  the  pneumonia.  Thirdly,  pneumonia  may  actually  be  present  and  yet  the 
rhonchus  be  wanting,  from  the  circumstance  that  the  respiration  is  too  feeble  to 
force  the  air  into  the  engorged  vesicles,  owing  to  the  age  of  the  patient,  or  the 
debility  produced  by  preceding  disease.  For  an  analogous  reason,  of  an  oppo- 
site kind,  tin;  crepitous  rhonchus  may  be  sometimes  perceptible  when  there  is 
no  pneumonia,  in  tlu-  case  of  children,  the  extreme  power  of  whose  respiration 
may  excite  in  their  diminutive  bronchial  ramifications  a  mere  mucous  rhonchus 
with  bubbles  as  small  as  those  which  constitute  the  crepitous.— (Jtf.  L.) 

I  still  think  the  crepitous  rhonchus,  although  occurring  almost  constantly 
in  the  first  stage  of*  pneumonia,  is  not  a  pathognomonic  symptom  of  this  affec- 
tion. It  may  be  met  with  in  a  great  many  cases,  where  certainly  nothing  exists 
but  simple  bronchitis,  either  acute  or  chronic,  when  inflammation  is  seated  in 
the  small  ramifications  of  the  bronchi,  and  they  become  filled  with  a  viscous 
fluid,  obstructing  the  transmission  of  the  air.  The  crepitous  rhonchus  differs 
from  the  mucous  rhonchus  only  by  simple  shades,  and  they  often  approach  so 
near  as  to  be  confounded  together.— Andral. 


PNEUMONIA.  223 

especially  when  existing  near  the  roots  of  the  lungs,  that  bron- 
chophony is  rendered  much  stronger  by  the  interposition  of  a 
small  layer  of  fluid  ;  and  it  is  in  this  case  that  the  co-existence  of 
aegophony  gives  rise  to  the  mixed  phenomena  described  in  the 
First  Part.     Bronchophony  is  always  less  strongly  marked  and 
more  diffused,  in  the  lower  parts  of  the  Jungs,  owing  to  the  lesser 
diameter  of  the  bronchi  there ;  and  becomes  quite  imperceptible 
in  this  situation  if  the  corresponding  parts  of  the  pleura  contain 
a  fluid.     The  bronchial    respiration  and    cough  always    accom-  I 
pany  bronchophony ;  and  the  former  are  sometimes  very  distinct 
when  the  latter  is  not  so.     In  this  case,  an  attentive  examination 
enables  us  to  discover  that  the  bronchial  respiration  and  cough 
have  their  seat  in  the  interior  of  the  lungs,  and  that  the  superficial 
parts  are  still  permeable  to  the  air,  or  simply  obstructed.     If  a 
rhonchus  exists  in  the  bronchi  at  the  same  time,  the  hepatiza- 
tion renders  it  much  stronger    and  more  distinct.     When    the 
hepatization  is  near  the  surface,  and  involves  within  it  bronchial 
tubes  of  a  considerable  size,   as  when  it  has  its  seat  at  the  roots 
or  in  the  top  of  the  lungs,  bronchophony  becomes  then   almost 
like  pectoriloquy.     In  this  case  it  is  frequently   accompanied  by 
the  sensation  of  blowing  into  the  ear,  and  if  a  thin  portion  of 
pulmonary  substance,  not   yet  hepatized,   intervenes  betwen  the 
ear  and    the    affected    bronchi,  the  sensation  denominated    the 
veiled  puff,  is  produced.     As  long  as  the  inflammation  increases, 
the  crepitous  rhonchus  extends*  daily  around   the  hepatized  part, 
or  arises  in  new  points ;  it  precedes   the  signs  of  hepatization, 
which    commonly  are    found  on  the  following   day  very   distinct 
in  those  points  where  the  crepitous  rhonchus  had  existed  the  day 
before.* 

These  are  the  physical  signs  of  hepatization ;  which  is  always 
further  accompanied  by  a  dull  sound  on  percussion,  over  the  af- 
fected parts  ;  except  in  the  case  where  the  pneumonia  is  central. 
In  this  case,  and  especially  of  the  hepatization  occupies  the  cen- 
tre of  the  left  inferior  lobe,  and  the  lower  part  of  the  right  side 
be  naturally  imperfectly  sonorous,  as  commonly  happens,  per- 
cussion will  frequently  furnish  us  with  no  useful  result,  or  will 
at  most  lead  us  to  suspect  the  affection  of  the  left  lower  lobe. 
For  the  same  reason,  if  the  hepatization  occupies  the  right  infe- 
rior lobe,  percussion  will  only  then  enable  us  to  recognize  its 
presence,  where  we  had  previously  ascertained  the  natural  sono- 
rousness of  this  part ;  since  there  are  many  persons  in  whom  the 
right  side  of  the  chest,  as  high  as  the  fourth  or  fifth  rib,  is  natur- 

*  It  is  an  important  practical  precept — always  to  attend  the  presence  of  an 
unequally  strong,  although  still  perfectly  pure  or  healthy  respiration  ;  as  it 
almost  "always  indicates  obstruction  in  some  other  part  of  the  same  or  opposite 
lung.     This  is  especially  the  case  in  pneumonia. —  Transl. 


224  PNEpMONIA. 

ally  destitute  of  sound.     In  almost   all   cases,  where  the  points 
hepatized  are  of  small  extent,  percussion  gives  us  no  assistance. 

Signs  of  suppuration. — The  infiltration  of  pus  within  the  pul- 
monary tissue  furnishes  no  new  sign  so  long  as  the  pus  remains 
concrete.  When  this  begins  to  soften,  we  perceive  in  the  bronchi 
a  more  or  less  distinct  mucous  rhonchus,  occasioned  either  by  the 
introduction  of  the  pus  into  them,  or  by  a  more  copious  catarrhal 
secretion  which  then  takes  place. 

"t"  Signs  of  abscess. — When  the  pus  is  not  absorbed  or  expecto- 
rated in  proportion  as  it  becomes  softened,  but  collects  into  one 
spot,  a  very  strong  mucous  or  cavernous   rhonchus,  with   large 

,  bubbles,  is  perceived  over  the  site  of  the  abscess.  The  bron- 
chophony is  converted  into  pectoriloquy,  and  the  respiration  and 
cough  change  from  bronchial  to  cavernous.  If  the  abscess  is  near 
the  surface,  the  respiration  and  cough  yield  the  puffing  respira- 
tion, and,  according  to  circumstances,  the  veiled  puff.  These 
signs  are  almost  always  easily  distinguished  from  the  analogous 
phenomena  which  exist  in  hepatization,  viz.  bronchophony,  bron- 
chial cough  and  respiration,  and  bronchial  mucous  rhonchus.  A 
little  experience  will  enable  us  to  discriminate  the  bronchial 
from  the  cavernous  phenomena.  The  latter  always  are  distinctly 
circumscribed,  and  appear  to  have  their  site  in  a  space  larger 
than  any  bronchial  trunk.  The  intensity  of  the  rhonchus  when 
the  abscess  is  only  half  full,  the  stuttering  sound  of  the  pectori- 
loquy in  the  same  case,  and  the -small  extent  of  the  peripneumo- 
nic  affection  (which  had  either  been  partial  from  the  beginning,  or 
is  now  become  so  by  the  resolution  of  the  remaining  parts),  are 
additional  signs  which  in  most  cases  leave  no  room  for  doubt. 
On  the  other  hand,  the  bronchial  phenomena  are  remarkable  by 
their  diffused  character  ;  bronchophony  when  most  like  pectoril- 
oquy, always  differs  from  it  in  this  respect :  moreover,  in  broncho- 
phony the  voice  rarely  traverses  the  whole  extent  of  the  cylinder ; 
it  is  also  pure  in  this  case,  or,  if  accompanied  by  a  mucous  rhon- 
chus, which  is  not  common,  this  has  never  the  exact  circumscrip- 
tion, and  rarely  has  the  intensity,  of  the  cavernous  rhonchus.* 

This  distinction  between  the  bronchial  and  the  cavernous  phenomena,  is  of 
great  practical  importance.  But  the  question  for  consideration  is — whether 
these  cavernous  signs  really  do  exist  sometimes  in  pure  pneumonia?  Two  events 
must  have  been  previously  established  before  wo  can  resolve  this  question  in  the 
affirmative  :  1st,  the  existence  of  an  excavation  in  the  lungs  containing  pus, 
communicating  with  the  bronchi,  and  partly  empty;  2dly,  the  co-existence  along 
with  the  cavernous  signs  (in  certain  cases  atHeast)  of  a  considerable  expectora- 
tion of  pus.  runiing  on  rather  suddenly;  for  it  is  evident,  that  so  long  as  the 
abscess  consists  in  a  close  bag  of  pus  amid  a  mass  of  hepatized  lung,  (and  this  is 
the  only  form  in  which  pulmonary  alj~re<~  has  yet  been  observed,)  there  can  be 
neither  pectoriloquy  nor  the  cavernous  rhonchus.  .Now.  1  think  ii  necessary  to 
remark,  that  in  the  greater  number  of  the  cases  cited  above  by  Laennec,  as  ex- 
amples of  pulmonary  abscess  cured,  this  essential  co-existence  of  purulent  ex- 
pectoration with  the  cavernous  phenomena  was  not  observed  ;  neither  did  there 
exist  that  exact  circumscription  which  these  phenomena  ought  to  present. —(M.  /..) 


PNEUMONIA.  225 

Signs  of  resolution. — When  resolution  takes  place  before  he- 
patization has  supervened,  the  crepitous  rhonchus  becomes  daily 
less  perceptible,  while  the  natural  sound  of  respiration  becomes 
gradually  more  distinct,  and  at  last  is  alone  heard.  When  hepa- 
tization has  taken  place,  its  resolution  is  invariably  announced  by 
the  return  of  the  crepitous  rhonchus.  I  have  never  seen  this  sign 
wanting  in  any  case  which  I  have  been  able  to  examine  daily :  I 
commonly  denominate  it — the  renewed  crepitous  rhonchus  (rhon- 
chus crepitans  redux).  M.  Andral  has  noticed  it  in  most  of  his 
examples  of  pneumonia  cured.  (Obs.  xi.  xii.  xiii.  xv.  xvi.  xxxviii. 
xxxix).  To  the  crepitous  rhonchus  is  gradually  joined  the  na- 
tural sound  of  respiration,  which  becomes  daily  more  distinct, 
and  at  last  exists  alone.  The  crepitous  rhonchus  equally  an- 
nounces the  resolution  of  the  pneumonia  when  it  has  arrived  at 
the  stage  of  suppuration ;  but  in  this  case  it  is  usually  preceded 
by  a  mucous  or  submucous  rhonchus,  indicating  the  softening 
of  a  part  of  the  pus.  In  this  case  the  natural  sound  of  respira- 
tion returns  much  more  slowly  than  in  the  preceding  instances. 
At  the  expiration  of  a  few  days,  or  even  sometimes  of  a  few  hours, 
the  crepitous  rhonchus  becomes  subcrepitous,  indicating  the  su- 
pervention of  oedema,  which  usually  attends  the  resolution  of  this 
stage  of  pneumonia.  The  same  thing  is  observed  when  oedema 
accompanies  the  resolution  of  the  other  two  stages  of  the  inflam- 
mation. When  the  disease  has  extended  to  the  greater  part  of  the 
lungs,  the  extreme  points  and  the  parts  most  recently  attacked  are 
usually  those  in  which  resolution  commences :  the  contrary,  how- 
ever, is  sometimes  the  case. 

There  are  some  cases  in  which  it  is  more  difficult  to  obtain  the 
physical  sign  of  peripneumony,  especially  in  the  early  period  of 
the  disease.  These  difficulties  are  owing — 1,  to  the  inflammation 
being  seated  in  the  central  parts  of  the  lungs,  and — 2,  to  its  be- 
ing complicated  with  other  affections.  M.  Andral  met  with 
these  difficulties,  and  he  appears  to  have  exaggerated  their  de- 
gree ;  as  he  goes  so  far  as  to  say,  that  not  only  the  central  pneu- 
monia, but  those  seated  at  the  roots  and  base  of  the  lungs,  can- 
not be  ascertained  by  auscultation.  I  can  however  state,  as  the 
result  of  my  own  experience,  that.  I  have  only  met  with  one 
single  case  of  what  appeared  to  me  pneumonia,  in  which  all 
the  stethoscopic  signs  were  wanting.  In  this  case,  there  was 
expectoration  for  one  or  two  days  of  the  real  peripneumonic 
sputa,  to  be  hereafter  described,  and  which  have  always  appeared 
to  me  to  coincide  with  the  first  stage  of  the  disease ;  but  on  exam- 
ination I  detected  neither  crepitous  rhonchus  nor  bronchophony. 
The  six  first  cases  of  M.  Andral  (obs.  xxx. — xxxv.)  were  of  the 
same  kind,  being  very  slight,  indicated  only  by  peculiar  expec- 
toration,-and  all  terminating  in  prompt  resolution.  In  opposition 
29 


226  PNEUMONIA. 

to  these,  I  might  here  adduce  a  vast  number  of  cases,  in  which 
not  only  myself,  but- pupils  who  had  not  practised  auscultation 
six  months,  have  recognized,  by  means  of  the  crepitous  rhonchus, 
central  pneumonia  of  not  greater  dimensions  than  an  almond  or 
filbert.  (See  Case  IV.)  I  would  therefore  affirm,  in  conclusion, 
that,  if  examined  from  the  very  beginning,  central  peripneumo- 
nies,  and  those  denominated  lobular,  (which  begin  in  many  small 
points  at  the  same  time,)  are  very  easily  recognized  in  most 
cases,  and  only  require  particular  care  when  the  inflamed  portions 
are  very  small.  It  is  moreover  to  be  here  observed,  that  cases  of 
this  kind  are  slight,  and  are  unattended  witli  danger  unless  they 
extend ;  in  which  case  the  stethoscopic  signs  become  distinctly 
evident,  and  in  sufficient  time  for  practical  purposes.  I  have 
often  ascertained  the  presence  of  small  inflamed  points  at  the 
roots  and  base  of  the  lungs.  In  the  former  place,  more  particu- 
larly, we  can  often  recognize  the  crepitous  rhonchus  at  a  great 
depth ;  and  when  it  is  at  the  surface,  it  is  as  readily  heard  as  in 
any  other  point.  Small  inflamed  spots,  in  the  centre  of  the  base 
of  the  lungs,  are  unquestionably  more  difficult  of  recognition 
than  any  other ;  yet  even  here  the  crepitous  rhonchus  is  often 
very  distinctly  perceived.  But  we  can  not  only  recognize  the  ex- 
istence of  pneumonia  of  moderate  extent  in  the  centre  of  the  lungs, 
but  we  can  also  ascertain  that  it  is  central.  In  this  case,  at  the 
beginning,  the  crepitous  rhonchus  is  heard  profoundly  in  a  cir- 
cumscribed spot,  while  more  superficially  the  ordinary  murmur 
of  respiration  is  heard  pure,  and  sometimes  almost  puerile.  The 
la'st  character  is  especially  observed  when  there  are  several  spots 
inflamed  at  the  same  time.  When  the  stage  of  hepatization  su- 
pervenes, the  bronchial  respiration  is  heard  profoundly',  while 
the  ordinary  respiration  is  heard  on  the  surface.  Sometimes 
even  we  can  ascertain  a  profound  bronchophony  and  bronchial 
cough-  The  peculiar  and  distinctive  character  of  these  pheno- 
mena, when  profound  or  superficial,  can  easily  be  ascertained  by 
a  person  of  only  moderate  experience.  I  have  known  pupils, 
who  had  practised  auscultation  only  three  months,  make  the 
distinction  without  hesitation.  This  distinction  is  of  great  im- 
portance ;  as  it  is  in  the  diagnosis,  and  consequently  in  the 
treatment  of  pneumonia,  as  I  have  already  remarked,  that  the 
greatest  practical  benefit  of  auscultation  will  be  found;  since 
every  physician  will  be  ready  to  admit,  that  the  earlier  we  ascer- 
tain the  existence  of  this  disease  the  more  easily  it  is  cured. 
When  a  central  peripneumony  approaches  the  surface,  we  per- 
ceive that  the  superficial  sound  of  the  natural  respiration  occu- 
pies a  smaller  space  at  each  succeeding  exploration;  while  the 
bronchial  respiration  and  bronchophony  gradually  approach  the 


PNEUMONIA.  22" 

surface,  and  finally  reach  it,  within  a  space  which,  at  first,  might 
be  covered  by  the  finger.* 

Of  all  the  affections  of  the  organs  of  respiration  which  may  be 
combined  with  pneumonia,  the  suffocative  catarrh  is  unquestion- 
ably that  which  most  marks  its  characteristic  signs.  If  the  pneu- 
monia is  of  a  very  small  extent,  and  supervenes  to  the  catarrh, 
if  is  possible  that  it  may  be  masked  by  the  presence  of  the  very 
loud  mucous  rhonchus  which  exists  over  the  whole  bronchi.  It 
is  this  circumstance  which  renders  the  pneumonia  of  the  dying 
so  difficult  to  be  recognized.  However,  even  in  this  case,  as  often 
as  I  have  wished  to  ascertain  the  pneumonia,  in  order  to  exercise 
the  pupils,  I  have  always  been  able  to  perceive  the  crepitous  in 
the  middle  of  the  mucous  rhonchus.  As  far  as  regards  the  com- 
plication with  the  suffocative  catarrh,  (which  is,  by  the  way,  a 
very  rare  disease,)  the  difficulty  of  diagnosis  is  of  no  practical 
importance ;  for  when  this  complication  takes  place,  either  the 
patient  dies  before  the  pneumonic  affection  is  in  itself  of  any 
severity  ;  or  if  the  progress  is  slower,  the  crepitous  rhonchus  and 
other  signs  of  pneumonia  make  their  appearance.  The  dry  ca- 
tarrh would  at  first  sight  seem  to  be  a  very  likely  means  of  pre- 
venting the  development  of  the  crepitous  rhonchus;  while  the 
frequency  of  this  affection  would  thus  cause  pneumonia  to  be 
frequently  mistaken,  especially  at  its  onset.  I  have  not  found 
in  practice,  however,  that  the  crepitous  rhonchus  was  more  diffi- 
cultly perceived  in  subjects  affected  with  dry  catarrh  than  in 
others :  I  have  only  observed  that  the  respiration  does  not  be- 
come so  puerile  in  the  sound  parts  as  in  other  cases.  It  is  pro- 
bable that  the  inflammation  of  the  pulmonary  substance  pro- 
duces, at  least  in  the  first  instance,  a  derivation,  which  unloads 

*  I  can  hardly  agree  with  our  author  as  to  the  certainty  of  detecting  all  the 
preceding  varieties  of  partial  pneumonia  by  the.  .stethoscope.  His  tact  and 
experience  were  certainly  matchless;  and  no  doubt  he  did  what  few  of  hi* 
followers  can   accomplish.     At   all  events.  I  think  the  student,  ought  hardly  to 

expect  to  c pass  so   minute. a  diagnosis  j  as  failure  might  weaken  his  conf- 

dence  in  the  unquestioned  and  unquestionable  powers  of  the  instrument.  The 
following  remarks  on  this  point,  by  Dr.  Williams,  are  particularly  deserving  the 
attention  of  the  young  practitioner  : — "  It  has  always  appeared  to  me,  that  the 
more  the  student  in  auscultation  holds  in  view  the  pathological  state  on  which 
the  signs  depend,  rather  than  those  signs  themselves,  and  habitually  reflects  on 
their  physical  mechanism,  as  far  as  it  is  known,  without  empirically  dwelling 
on  the  names  or  bare  descriptions  of  sound,  the  more  surely  will  he  estimate 
the  value  of  this  method  of  diagnosis,  and  the  more  instruction  will  he  receive 
from  it.  lie  will  thus  see  that  central  peripneumony  may  be  so  situated  as  to 
yield  sometimes  no  physical  symptom,  and  at  others  these  to  be  discovered  only 
by  a  very  careful  examination  :  and  hence  he  will  see  the  impropriety  of  a  par- 
tial method  of  diagnosis,  and  the  greal  importance  of  attending  to  the  sputa  and 
other  indications.  When  the  inflammation  is  extensive,  all  these  difficulties 
vanish,  and  the  more  intense  and  puerile  respiration  in  the  sound  portions  of 
the  lung,  depending  on  the  more  rapid  and  forcible  passage  of  the  air  in  them 
further  shows  the  infringement  that  has  been  made  on  the  proper  function  of 
the  organ."     (Cyc.  of  Pract.  Med.  vol.  iii.  p.  421.)—  Transl. 


228  PNEUMONIA, 

the  smaller  bronchial  ramifications.  A  tumor  which  should 
entirely  compress  the  large  bronchial  trunk  would,  no  doubt, 
cause  all  the  stethoscopic  signs  to  disappear ;  but  I  know  of  no 
example  of  such  a  case ;  and  we  have  already  seen,  that  a  poly- 
pus occupying  nineteen-twentieths  of  the  diameter  of  one  of  the 
principal  bronchi,  did  not  impede  the  manifestation  of  pectori- 
loquy and  the  cavernous  rhonchus.  Had  this  patient  been  at- 
tacked with  pneumonia  we  ought  equally  to  have  heard  the 
crepitous  rhonchus. 

Symptoms  depending  on  the  disorder  of  the  functions  of 
the  lungs. — These  usually  are — an  obtuse  and  deep-seated  pain, 
dyspnoea,  quick  respiration,  cough,  and  expectoration  of  a  pecu- 
liar kind.  To  these  symptoms,  decubitus  on  the  affected  side  is 
commonly  added  ;  but  nothing  is  more  variable  than  this.  The 
other  symptoms  are  more  constant,  though  each  of  them  may  be 
wanting,  and  even,  in  particular  cases,  all  of  them  may  be  so  at 
the  same  time.  Moreover,  they  may  all  co-exist  in  many  other 
diseases  as  well  as  pneumonia  ;  and  each  of  them  exhibits  many 
varieties.  Thus  the  pain,  which  is  commonly  slight  and  exten- 
sively diffused,  is  sometimes  confined  to  a  point,  even  when  there 
is  no  accompanying  pleurisy.  However,  when  it  becomes  very 
acute,  it  is  commonly  on  account  of  the  inflammation  being  ex- 
tended to  some  part  of  the  pleura.  The  dyspnoea  is  often  hardly 
perceived  by  the  patient,  although  the  frequency  of  the  respira- 
tion points  it  out  to  the  physician  ;  in  some  cases  this  is  not 
more  frequent  than  in  health.  When  dyspnoea  does  exist,  the 
inspection  of  the  chest  will  not  enable  us  to  decide  whether  or 
not  it  depends  on  an  organic  affection  of  the  lungs,  as  the  dila- 
tation of  the  chest  and  the  elevation  of  the  ribs  are  often  equal 
on  the  sound  and  diseased  side, — a  remark  which  has  also  been 
made  by  M.  Andral  (Op.  Cit.  p.  330.)  The  cough  is  commonly 
frequent  and  pretty  strong ;  but  sometimes  it  is  so  slight  as  to 
be  denied  by  the  patient  and  the  attendants.  The  expectoration 
ii  a  great  many  cases  has  an  appearance  quite  characteristic,  and 
vhich,  in  my  opinion,  may  by  itself  enable  us  to  recognize  the 
disease,  as  I  have  never  met  with  it  in  any  other.  These  sputa, 
waich  I  shall  term  glutinous  or  pneumonic,  when  received  into 
a  flat  and  open  vessel,  unite  into  so  viscid  and  tenacious  a  mass, 
that  we  may  turn  it  upside  down,  even  when  full,  without  the 
sputa  being  detached,  although  they  may  partially  hang  from 
the  vessel's  mouth.  If  we  shake  the  vessel  its  contents  'vibrate 
like  jelly,  but  in  a  less  degree.  The  color  of  this  expectoration 
is  frequently  some  shade  of  red,  particularly  that  of  rust ;  or  it 
is  sea-green,  tawny,  orange,  saffron,  yellowish,  or  a  dull  green. 
These  various  colors  are  frequently  intermixed,  in  stripes,  in 
the  same  spitting-pot ;  and  are  evidently  owing  to  blood  exist- 


PNEUMONIA.  229 

ing  in  a  greater  or  less  proportion,  or  more  or  less  intimately 
combined  with  the  expectorated  matter.  The  shades  of  green 
appear  to  me  to  depend  on  the  same  cause,  although  they  con- 
stitute the  bilious  sputa  of  Stoll  and  his  disciples.  Certain  it  is, 
that  I  have  frequently  met  with  them  in  cases  where  there  ex- 
isted no  bilious  complication ;  although  I  must  admit,  at  the 
same  time,  that  I  have  sometimes  seen  them  disappear,  after 
bilious  evacuations.  The  entire  body  of  the  expectoration  has 
a  semi-transparency  like  that  of  horn,  and  sometimes  it  is  almost 
as  transparent  as  white  of  egg  very  slightly  colored.  Air- 
bubbles  of  unequal  size  and  sometimes  very  large,  are  contained 
in  great  number  in  the  expectoration,  and  cannot  escape  on  ac- 
count of  its  great  tenacity.  If  sputa  of  this  kind  existed  con- 
stantly in  pneumonia,  we  should  require  no  other  sign  to  indicate 
its  presence.  They  commonly  appear  in  the  stage  of  engorgement, 
and  retain  their  character  until  hepatization  is  well  advanced ; 
they  then  vary  much  from  the  characters  above  described,  as  we 
shall  see  presently.  It  is  to  be  remarked,  however,  that,  even  in 
the  first  stages,  they  do  not  always  present  the  strongly-marked 
features  we  have  just  described.  Frequently  they  are  less  vis- 
cid, little  colored,  and  nearly  destitute  of  air-bubbles ;  and  at 
other  times  we  perceive  only  a  few  glutinous  and  slightly  tawny 
sputa,  amid  a  great  mass  of  mucous  or  pituitous  expectoration. 
Pretty  frequently,  the  characteristic  sputa  are  observed  only  at 
the  very  onset  of  the  disease,  and  during  a  few  hours ;  and  some- 
times they  do  not  show  themselves  even  at  this  period,  or  they 
are  in  such  small  quantity  as  hardly  to  admit  of  being  collected. 
This  appears  particularly  the  case  in  old  subjects,  and  in  very 
rapid  attacks,  and  also  in  the  pneumonia  of  the  dying.  The  cha- 
racter of  the  expectoration  is  much  more  marked  in  certain  epi- 
demic constitutions  than  in  others.  This  was  particularly  the 
case  in  the  catarrhal  epidemic  of  1803,  denominated  the  grippe. 
The  numerous  cases  of  pneumonia  which  occurred  during  the 
winter  of  this  year  were  all  marked  by  the  peculiar  expectora- 
tion ;  which  was  so  very  different  from  that  attending  the  pre- 
vailing catarrh,  that  M.  Bayle  and  myself,  who  noticed  it  then 
for  the  first  time,  were  surprised  at  not  being  able  to  find  an  ex- 
act description  of  it  in  authors.  Since  that  time,  on  the  other 
hand,  I  have  seen  constitutions  in  which  the  glutinous  expecto- 
ration was  unusual,  and  much  less  strongly  marked.  During 
the  period  of  hepatization  the  expectoration  is  slight  and  variable 
in  character ;  it  usually  consists  of  a  small  quantity  of  pituitous 
sputa,  more  or  less  viscid  and  vitriform,  or  of  a  whitish  or  yel- 
lowish and  half-opaque  mucus.  After  the  purulent  infiltration 
occurs,  the  expectoration  is  more  decidedly  mucous,  and  like 
that  in  the  latter  stage  of  catarrh.     Sometimes  it  contains  specks 


230  PNEUMONIA. 

of  a  yellowish-white  color  not  unlike  milk,  as  if  from  an  admix- 
ture of  pus :  rarely  the  expectoration  becomes  entirely  purulent. 
Lerminier  and  Andral  consider  an  expectoration  of  sputa,  which 
seem  to  consist  of  a  mixture  of  blackish  blood  and  diffluent  pi- 
tuita,  as  characteristic  of  the  period  of  suppuration.  I  have 
frequently  met  with  this  kind  of  expectoration,  which  greatly 
resembles  the  juice  of  prunes,  (as  M.  Andral  has  remarked.)  but 
as  it  always  appeared  to  occur  in  cachectic  subjects,  with  spongy 
bleeding  gums,  and  even  in  persons  without  any  pneumonic  affec- 
tion, I  have  not  paid  particular  attention  to  it  as  a  sign  of  pneu- 
monia. I  do  not  even  think  that  the  opinion  of  M.  Andral  is 
satisfactorily  made  out  by  a  reference  to  his  own  cases.* 

General  symptoms  and  progress. — Pneumonia  is  attended  by 
active  fever  from  its  very  invasion.  It  is  only  in  very  rare  cases 
that  this  is  wanting,  or  even  that  it  is  inconsiderable ;  indeed, 
this  happens  only  when  the  disease  is  partial,  and  of  small  extent. 
The  presence  of  this  degree  of  fever  accounts  for  the  flushing  of 
the  face,  and  the  various  sanguineous  and  serous  congestions, 
which  such  a  state  of  the  system  usually  occasions  in  the  brain 
and  its  membranes,  and  in  the  intestinal  canal.f     When  the  de- 

*  The  safest  conclusion  to  come  to,  in  my  opinion,  respecting  this  prunc-juicc 
or  liquorice-juice  expectoration  in  pneumonia,  is  to  regard  it  as  indicative  of  the 
complication  with  pulmonary  apoplexy,  in  every  case  where  the  condition  of 
the  gums,  &c.  does  not  indicate  a  cachectic  or  scorbutic  diathesis.  It  is,  at  least, 
much  more  probable,  that  the  darkish  hue  and  great  liquidity  of  the  sputa, 
should  be  owing  to  blood  rather  than  to  pus. — (M.  L.) 

The  expectoration  which  has  been  compared  by  me  to  the  juice  of  prunes,  I 
do  not  consider  as  pathognomonic  of  purulent  infiltration  of  the  lungs.  I  only 
affirm  that  the  existence  of  this  expectoration  coincides  more  often  with  the 
third  stage  of  pneumonia,  than  with  the  first  or  second  stage.  I  have  satisfied 
myself  that  in  many  cases  which  1  have  seen,  this  prune-juice  expectoration 
could  not  be  ascribed  either  to  pulmonary  apoplexy  or  a  scorbutic  condition  of 
the  gums. — Andral. 

\  For  a  very  excellent  and  full  account  of  the  expectoration  in  peripneumony, 
I  refer  the  reader  to  Andral's  admirable  work  so  often  quoted,  p.  339.  The 
variety  of  expectoration  just  noticed  as  resembling  the  juice  of  prunes,  or  of 
liquorice,  is  noticed  by  Huxham  as  occurring  in  scorbutic  patients.  lie  describee 
it  as  "  livid,  gleetv,  and  sanious,  frequently  resembling  the  lees  of"  red  wine, 
sometimes  more  black,"  &c. — Essay  on  Fevers,  fyc.  p.  210.  I  would  here  re- 
mark, that  Huxham  gives  a  fuller  account  of  the  varieties  of  expectoration  in 
pneumonia  than  any  other  English  author,  although  his  account  is  very  defective. 
It  is,  indeed,  surprising  so  observe  how  little  attention  is  paid  by  most  of  our 
practical  authors  (and,  I  might  add,  practitioners)  to  this  most  important  symp- 
tom, while  every  trifling  and  insignificant  variety  of  pulse,  tongue,  stools,  &c. 
is  dwelt  on  with  tiresome  minuteness.  I  would  particularly  request  the  atten- 
tion of  young  practitioners  to  the  expectoration,  in  all  diseases  of  the  lungs; 
and  can  assure  them  they  will  derive  more  useful  information  from  it  than  from 
many  other  things  they  are  accustomed  to  observe  with  much  greater  can  A 
spitting-pot  I  consider  as  an  essential  part  of  the  bed-room  apparatus  of  the 
pulmonic  patient,  and  its  daily  inspection  is  an  imperative  duty  of  the  medical 
attendant.  To  those  who  do  "not  practise  auscultation,  this  kind  of  observation 
is  particularly  necessary,  as  otherwise  they  will  constantly  be  deceived  in  their 
diagnosis.  Children  generally  swallow  their  expectoration' ;  voung  persons,  and 
even  adults,  often  do  the  same  ;  and  I  have  more  than  once  discovered  the  ex- 
istence of  pneumonia  in  such  cases,  by  taking  measures  to  obtain  a  sight  of  the 
sputa. —  Transl. 


PNEUMONIA.  231 

termination  of  blood  to  the  head  is  very  great,  and  marked  by 
coma  in  the  beginning  of  the  disease,  as  often  is  the  case  in  old 
persons  of  a  plethoric  habit,  the  symptom  is  extremely  unfavor- 
able ;  as  the  patients  in  whom  it  occurs  usually  die  before  hepa- 
tization  is  completely  established  ;  or   the   inflammation  reaches 
the  stage  of  purulent   infiltration   in  the  space   of  a  few  hours. 
A  furious  delirium   is  a  much  less  dangerous   symptom.*     Con- 
gestion of  blood  in  the  stomach  is    indicated  by  a    very  intense 
redness  of  the   tongue,  and  sometimes  by  its  becoming  soft  (par 
son  ramollissement.)     It    is  unusual  for  the  epigastrium   to  be 
very  painful ;  or,   rather,  it  is   hard  to  say   whether  the  patients 
suffer  from  pain  in   the   stomach,  produced  by  the   pressure,  or 
from  the  impediment  thereby  occasioned  to  respiration.  Diarrhoea 
sometimes  takes  place,  especially  if  the  fever  is  of  some  standing. 
In  respect  of  this  symptom,  I  would  observe,  in  common  with 
most  practitioners,  that  it  is  not  a  bad  sign,  especially  if  it  comes 
on  towards  the  latter  part  of  the  disease,  and  is  moderate.     The 
pneumonic  fever  may  be  accompanied  by.  a  bilious  affection  ;  a 
complication  which  was  very  common   towards  the  close   of  last 
century,  but  which  is  now  extremely  rare.     Almost  all  the  pneu- 
monia observed  by  Stoll  were  bilious ;  and  I  was  myself  witness 
of  many  similar  cases  when  I  attended  the  lectures   of  Corvisart. 
Since  1804,  however,  I  have  met  with   no  well-marked  example 
of  the  kind.     I  formerly  remarked,  that  we  must  be  cautious  in 
admitting  the   presence  of  bile  in  the  expectoration,  even   when 
this  is  of  a  greenish  yellow.     The  fever  in   pneumonia  is  truly 
symptomatic,  that  is  to  say,  is  the  effect  of  the  inflammation.     It 
rises  and  falls  with  the  inflammatory  orgasm.     It  even  frequently 
happens,  that  as  soon  as  this   latter  is  checked  by  the  lancet  or 
otherwise,  the, fever  ceases  entirely,  although   the  perfect  resolu- 
tion of  the  pulmonary  engorgement  will   not  be  accomplished  in 
less  than  a  fortnight,  three  weeks,  or  even  a  month.     Occasion- 
ally when  the  resolution   takes  place  slowly,  after  the  patient  has 
been  free  from  fever  for  several  days,  the  pulse  resumes  its  fre- 
quency, (but  not  its  fullness,)  and  the  skin   becomes  somewhat 
heated.     This    febricula,    however,  is    not   usually  followed    by 
any  mischief,  and  frequently  does  not  even  prevent  the  return  of 
a  good  appetite.     There  are  cases  of  a  different  kind,  where  the 
fever  continues,  and  with  equal  severity,  although  the  inflamma- 
tion is  in  the  progress  of  resolution.     In  these,  the  pneumonia  is 
complicated  with  an  idiopathic^  fever,  or,  at  least,  a  fever  de- 


*  The  general  opinion  of  writers  is,  that  delirium  is  an  extremely  dangerous 
symptom.  It  is  so  stated  by  Cullen,  Frank,  &c.  Lommius  says,  (Obs.  med. 
Lib.  secund.  p.  136,)  "  Potissimum  lethalis  est  cum  insaniam  movit."  I  remem- 
ber the  late  Dr.  Gregory  to  have  stated  in  his  lectures  that  he  had  only  known 
one  patient  recover  who  had  bad  delirium. —  Transl. 

t  I  make  use  of  the  term  idiopathic  (essentielk)  for  want  of  a  better,  to  ex- 


232  PNEUMONIA. 

pending  on  other  causes  than  the  inflammation  of  the  lungs. 
During  the  acute  stage  of  pneumonia,  the  urine  is  of  as  deep  a 
red  as  if  it  held  blood  in  solution  ;  and  this  character  is  as  strong- 
ly marked  in  it  as  in  any  inflammatory  disease  whatever.  The 
blood  drawn  from  the  veins  quickly  coagulates,  and  exhibits  a 
thick  coat  of  fibrin,  especially  at  the  first  bleedings. 

Pneumonia  frequently  terminates  favorably  by  a  distinct 
crisis,  not  only  in  the  cases  where  the  mildness  of  the  attack,  or 
ignorance  of  its  character,  have  occasioned  the  disease  to  be  left 
to  the  unassisted  efforts  of  nature,  but  even  when  repeated  vene- 
sections have  been  employed  without  any  benefit.  The  most 
common  of  these  critical  evacuations  is  a  lateritious  or  white 
sediment  in  the  urine  ;  and  we  should  distrust  any  other,  unless 
this  also  occurs  at  the  same  time.  After  this  deposition,  a  sweat 
and  moderate  diarrhoea  are  the  most  common  forms  of  crisis. 
A  copious  expectoration  of  mucus  is  also  sometimes  critical,  but 
much  less  frequently  than  the  practitioners  of  the  last  century 
believed,  unless,  indeed,  it  be  in  those  cases  which  occur  during 
the  course  of  a  catarrhal  epidemic.  Physicians  of  the  present 
age,  even  those  most  devoted  to  the  Hippocratic  method,  pay,  in 
general,  but  little  attention  to  the  crises  and  critical  days  of 
pneumonia  ;  the  rarity  of  the  instances  wherein  the  efforts  of 
nature  suffice  for  the  cure  of  the  disease,  leading  them  to  be- 
stow all  their  attention  on  the  indications  of  cure.  We  owe,  on 
this  account,  more  consideration  to  M.  Andral,  for  having  taken 
pains  to  verify  this  point  of  doctrine  in  his  cases  (Op.  Cit.  p.  365). 
Out  of  one  hundred  and  twelve  cases  of  pneumonia,  he  found 
forty-three  give  way  on  the  7th,  11th,  14th,  or  20th  day, — viz. 
on  the  days  most  usually  critical,  according  to  Hippocrates.  In 
twenty-six  other  cases,  the  days  could  not  be  ascertained.  In 
general,  if  we  observe  attentively,  we  shall  almost  always  find  that 
the  solution  of  the  disease,  even  when  effected  by  repeated  vene- 
sections, is  attended  by  a  critical  deposition  in  tjie  urine,  or  mois- 
ture on  the  skin. 

Occasional  causes. — The  most  common  of  these  is  the  im- 
pression of  cold,  either  long  continued,  or  received  when  the 
body  is  moderately  heated  and^covered  with  perspiration.  This 
cause  is  much  less  powerful  when  the  cold  immediately  succeeds 
to  an  excessive  heat,  and  is  not  prolonged  for  a  considerable 
time.     The  Russian  who  rolls  himself  in  the  snow  after  coming 

press  the  general  diseases,  denominated  by  the  ancients  simply — continued  or 
intermittent  fevers.  No  doubt,  before  the  cultivation  of  morbid  anatomy,  prac- 
titioners confounded  with  these  fevers  many  others,  which  are  in  reality  the 
symptom  of  an  internal  inflammation.  At  the  same  tiiuc.it  is  no  less  "true, 
that  both  fact  and  reasoning  accord  in  demonstrating  that  the  lesions  found  in  the 
intestinal  canal,  and  which  M.  Broussais  considers  as  the  cause  of  continued 
fevers,  are,  in  reality,  the  consequence  of  these.— Author. 


PNEUMONIA.  233 

out  of  the  hot  bath,  or  the  baker  who  goes  from  his  heated  oven, 
almost  naked,  into  an  atmosphere  of  a  temperature  below  zero,  is 
not  liable  to  attacks  of  this  disease  :  while  the  porters,  whose 
occupation  leads  them  to  stand  for  a  length  of  time  at  the 
corners  of  streets,  are  frequently  affected  by  it.  In  general,  pneu- 
monia is  a  disease  Of  winter  and  of  cold  climates  :*  it  is  rare  in 
the  equatorial  regions.  The  poison  of  serpents,  particularly  that 
of  the  rattle-snake,  frequently  induces  this  disease,  and  the  same 
result  follows  the  injection  of  various  mendicamentous  substances 
into  the  veins.f  It  is  probable  that  the  epidemic  peripneumony 
is  often  owing  to  an  analogous  cause,  that  is  to  say,  to  deleterious 
miasms  which  have  entered  the  system  by  means  of  the  cutane- 
ous or  pulmonary  absorbents ;  since  nothing  is  more  common 
than  to  meet  with  cases  of  this  disease  to  which  we  can  assign  no 
occasional  cause.  How  many  persons  are  seized  with  it  in  their 
very  chambers,  and  in  spite  of  the  utmost  care  taken  of  their 
health !  Most  pathologists  reckon  fullness  of  blood,  youth,  man- 
hood, arid  a  strong  constitution,  among  the  predisposing  causes 
of  pneumonia.  It  is  no  doubt  true,  that,  in  subjects  possessing 
these  conditions,  the  inflammation  is  more  acute,  the  fever  higher, 
and  the  disease  more  readily  recognized  and  cured  ;  but  it  is  no 
less  true  that  pneumonia  is  much  more  common  and  fatal  in  old 
persons :  it  is  in  such  subjects,  .more  particularly,  that  the  dis- 
ease runs  rapidly  into  suppuration.  Children  are  likewise  very 
subject  to  it,  and  the  more  so  the  younger  they  are.  In  them  the 
disease  is  frequently  mistaken,  because  they  swallow  the  expec- 
toration ;  and  death  most  commonly  takes  place  in  the  stage  of 
engorgement,  or  after  the  supervention  of  only  a  lobular  hepatiz- 

*  The  following  statistical  results,  extracted  from  Dr.  Williams's  excellent 
Treatise  on  Pneumonia  in  Cyclopaedia  of  Pracl.  Med.,  illustrate  this  point  satis- 
factorily :  they  are,  indeed,  only  in  accordance  with  the  common  observation  of 
practitioners.  "  Of  ninety-seven  cases  recorded  by  Louis  in  Chomel's  wards  at 
La  Charite  during  five  years,  eighty-one  occurred  between  February  and  August, 
mikI  only  sixteen  in  the  remaining  five  months  of  these  years.  Of  the  cases  de- 
scribed by  Andral,  the  number  occurring  in  March  and  April  amounted  to  a 
third  of  the  whole  :  the  fewest  took  place  in  May,  October  and  November,  and 
the  remaining  months  had  an  equal  share.  Of  two  hundred  and  forty-three 
eases  which  were  treated  at  the  Edinburgh  New  Town  Dispensary  during  three 
years,  ending  September  1.  1W'24,  sixty-seven  occurred  from  1st  September  to  1st 
December';  one  hundred  and  four  from  1st  December  to  1st  March  ;  ninety-four 
from  1st  March  to  1st  June  ;  and  sixty-eight  from  1st  June  to  1st  September. 
We  have  observed  in  London  nearly  an  equal  prevalence  of  the  djsease  from 
the  beginning  of  December  to  the  end  of  April,  and  a  considerably  smaller  pro- 
portion in  the  remaining  months  ;  but  it  appears  generally  that  the  latter  winter 
and  early  spring  months  are  must  fertile  in  producing  pneumonia  in  these  cli- 
mates."—  Trwhsl. 

\  These  well-known  facts,  and  others  of  an  analogous  kind,  tend  to  confirm 
the  truth  of  some  of  the  formerly  exploded,  but.  now  reviving,  doctrines  of  the 
humoral  pathology.  Many  physiological  and  pathological  facts  can  only  be  ex- 
plained on  the  supposition  of  an  immediate  alteration  in  the  composition  and 
qualities  of  the  circulating  fluids. —  Transl. 

30 


234  GANGRENE  OF  THE  LUNGS. 

ation,  that  is  to  say,  a  hepatization  occupying  only  some  de- 
tached points.  The  facility  with  which  they  fall  victims  to  this 
affection  even  in  its  onset,  is  explained  by  the  greater  necessity 
of  respiration  at  this  period  of  life.* 

Sect.  III. — Of  Gangrene  of  the  Lungs. 

This  is  rather  a  rare  disease.  It  can  scarcely  be  ranged  among 
the  terminations  of  pulmonary  inflammation,  and  still  less  can  it 
be  considered  as  the  consequence  of  its  intensity  ;  since  we  find, 
in  cases  of  this  kind,  the  inflammatory  character  very  slightly 
marked,  as  well  in  regard  of  the  symptoms,  as  of  the  engorge- 
ment of  the  pulmonary  substance.  It  would,  on  the  contrary, 
seem,  in  most  cases,  to  approach  the  nature  of  the  idiopathic 
gangrenes,  such  as  the  anthrax,  malignant  pustule,  pestilential 
bubo,  &c. ;  diseases  in  which  the  inflammation,  surrounding  the 
gangrenous  spot,  seems  to  be  rather  the  effect  than  the  cause  of 
the  sphacelus.  There  are  two  varieties  of  gangrene  of  the  lungs, 
which  are  strongly  marked  as  well  in  their  effects  as  in  their  ana- 
tomical characters.  These  are  the  uncircumscribed  and  the  cir- 
cumscribed. 

1.  Uncircumscribed  gangrene. — This  form  of  pulmonary  gan- 
grene may  be  reckoned  among,  the  rarest  of  organic  affections. 
In  the  course  of  twenty-four  years  I  have  only  met  with  it  twice  ; 
and  I  know  of  only  five  or  six  cases  of  it  that  have  occurred  in 
the  Parisian  hospitals  during  the  same  space  of  time.f     It  pre- 

*  The  following  statement  by  M.  Chomel  in  the  17th  volume  of  the  Diet,  de 
Med.  Article,  Pncumonie,  p.  21.1,  will  throw  some  light  on  the  liability  of  differ- 
ent ages  to  this  disease.  He  says,  that  out  of  fifty-six  individuals  affected  with 
pneumonia,  twenty-eight  were  from  twenty  to  thirty  years  of  age  ;  nine  from 
thirty  to  forty  ;  eleven  from  forty  to  fifty  ;  and  eight  from  fifty  to  sixty  ;  while, 
on  another  occasion  (the  epidemic  of  1812-13,)  of  one  hundred  and  thirty-four 
patients,  thirty-eight  were  from  fifteen  to  thirty  years  of  age  ;  thirty-four  from 
thirty  to  forty-five  ;  thirty-four  from  forty-five  to  sixty  ;  and  twenty-eight  above 
sixty.  Children  are  not  admitted  to  la  Chariti,  the  hospital  from  which  these 
statements  are  drawn  ;  but  respecting  the  great  prevalence  of  this  disease  in  in- 
fancy, the  testimony  of  M.  Guersent,  physician  to  the  Hospital  des  Enfans,  and 
a  person  of  vast  experience,  is  very  strong.  He  says  (Diet,  de  Med.  torn.  viii.  p. 
96.)  that  "  three-fifths  of  the  children  that  die  in  the  hospitals  between  birth  and 
the  conclusion  of  the  first  dentition,  die  of  pneumonia,  chiefly  in  a  latent  state." 
The  fatality  of  inflammation  of  the  lungs  in  children,  is,  no  doubt,  greatly  in- 
creased in  their  case,  by  the  difficulty  of  the  diagnosis,  owing  to  particular  cir- 
cumstances connected  with  their  tender  age.  In  no  case  is  the  stethoscope  more 
useful  than  in  this  ;  as  it  supplies,  at  once,  by  its  infallible  indications,  the  other- 
wise unsurmountable  deficiencies  in  the  diagnosis,  occasioned  by  the  inability 
of  the  patients  to  explain  their  feelings,  the  deglutition  of  the  sputa,  &c. — 
Transl. 

t  Dr.  Carswell  regards  the  frequency  of  this  affection,  as  considerably  under- 
rated by  Laennec,  and  informs  us,  that  he  had  himself  seen  twice  the  number  of 
cases  mentioned  by  Laennec,  in  the  same  hospitals,  during  a  period  of  not  more 
than  three  or  four  years.  (Cvc.  of  Pract.  Med.  vol.  Hi.,  Art.  Mortification,  p. 
124.) — Transl.  r 


GANGRENE    OF    THE    LUNGS. 


235 


sents  the  following  characters :  the  pulmonary  tissue  more  hu- 
mid and  less  cohesive  than  in  the  sound  state,  has  the  same 
degree  of  density  as  in  the  first  stage  of  pneumonia,  oedema  of 
the  lungs,  or  the  serous  engorgement  occurring  after  death ;  its 
color  varies  from  a  dirty  white  or  slightly  greenish  hue,  to  a 
deep  green  approaching  to  black,  with  a  mixture,  occasionally  of 
brown,  or  of  earthy  or  yellowish  brown.  These  different  shades 
are  mixed  irregularly  in  different  parts  of  the  lungs,  in  which 
we  likewise  observe  some  portions  of  a  livid  red  color,  more 
humid  than  the  rest,  and  seemingly  infiltrated  with  very  liquid 
blood,  precisely  as  in  the  first  stage  of  pneumonia.  Some  points 
here  and  there,  are  evidently  softened  and  converted  into  a  putrid 
deliquium ;  and  from  these,  when  cut  into,  there  flows  a  turbid 
sanies  of  a  greenish-grey  color,  and  of  an  insupportable  gangren- 
ous fetor. 

The  gangrenous  affection  occupies,  at  least,  a  great  portion  of 
one  lobe,  and  occasionally  the  greatest  part  of  one  lung :  it  is 
never  circumscribed.  In  some  places  the  pulmonary  substance, 
altogether  or  nearly  sound,  blends  insensibly  with  the  gangren- 
ous parts ;  in  other  instances,  these  are  separated  by  a  portion 
of  lung  inflamed  in  the  first  degree  ;  and,  in  still  rarer  instances, 
by  a  hepatized  portion.  If  the  disease  is  at  all  extensive,  its 
progress  is  extremely  rapid.  The  patient's  strength  is  prostrate 
from  the  very  beginning :  the  oppression  becomes  all  at  once 
extreme  ;  the  pulse  is  small,  compressed,  and  very  frequent ;  the 
cough  is  rather  frequent  than  strong ;  the  expectoration  is  dif- 
fluent, of  a  very  peculiar  green  color,  and  exhaling  an  extreme 
fetor  precisely  similar  to  that  of  a  sphacelated  limb*  This  ex- 
pectoration is  pretty  copious  for  a  time,  but  soon  ceases  through 
loss  of  power,  and  the  patient  dies  suffocated. 

2.  Circumscribed  or  idiopathic  gangrene. — This  differs  from 
the  preceding  variety  in  occupying  only  a  small  part  of  the  lungs, 
and  in  having  no  apparent  tendency  to  affect  the  neighboring 
parts.  From  this,  circumstance,  its  progress  is  much  slower ;  in- 
somuch that  it  has  been  ranged  by  Bayle  (Recherches,  p.  30) 
among  the  species  of  phthisis. 

Anatomical  characters. — This  partial  gangrene  may  occur 
in  any  part  of  the  lungs.  It  exists  in  three  different  states,  that 
of  recent  mortification  or  gangrenous  eschar,  that  of  deliquescent 
sphacelus,  and  that  of  an  excavation  produced  by  the  softening 
and  evacuation  of  the  sphacelated  spot.  These  gangrenous  eschars 
are  of  irregular  shape  and  of  very  variable  size.  Their  color 
is  black  verging  towards  green  ;  their  texture  more  humid,  more 
compact  and  harder  than  that  of  the  sound  lungs ;  their  general 

*  This  kind  of  expectoration  and  the  crepitous  rhonchus,  are  the  pathognomo- 
nic signs  of  this  affection. — Author. 


236  GANGRENE  OF  THE  LUNGS. 

appearance  extremely  like  that  of  the  eschar  produced  on  the 
skin  by  caustic;  and  their  odor  decidedly  gangrenous.  The 
portion  of  lung  immediately  surrounding  them  is  inflamed  and 
indurated  either  in  the  first  or  second  degree.  Sometimes  in  the 
progress  of  decomposition,  the  eschar  detaches  itself  from  the 
surrounding  parts,  like  that  produced  by  the  cautery  or  caustic 
potass,  forming  a  species  of  core  of  a  blackish,  greenish,  brown- 
ish, or  yellowish  color,  of  a  filamentous  texture,  and  more  flaccid 
and  drier  than  the  recently-formed  eschar.  This  core  remains 
isolated  in  the  middle  of  the  cavity  formed  by  the  decomposition 
of  the  sphacelated  portion.  More  commonly,  however,  the  eschar 
becomes  softened  throughout,  without  leaving  any  distinct  core, 
being  converted  into  a  kind  of  putrid  paste,  of  a  dirty  greenish- 
grey  color,  occasionally  bloody,  and  horribly  fetid.  This 
matter  soon  makes  its  way  into  some  of  the  neighboring  bron- 
chi, and  being  thus  gradually  discharged,  leaves  an  excavation 
of  a  truly  ulcerous  character.  The  pulmonary  substance  around 
the  excavation,  remains  long  inflamed  in  the  first  degree.  After 
the  lapse  of  several  days,  the  most  solid  portions  of  the  part  thus 
affected  have  hardly  attained  the  granular  character ;  they  are  of 
a  blackish-red,  very  humid,  and  containing  very  little  air.  When 
the  eschar  is  separated,  the  walls  of  the  excavation  become  the 
seat  of  a  secondary  inflammation,  which  seems  still  for  a  long 
time  to  retain  something  of  the  gangrenous  character :  the  walls 
are  invested  by  a  false  membrane  of  a  greyish  or  dirty  yellow 
color,  soft  and  opaque,  which  secretes  a  grumous  pus  of  the 
same  color,  or  a  black  sanies,  both  of  which  retain  the  gangren- 
ous fetor.  If  the  eschar  has  been  small,  the  false  membrane 
may  fill  the  whole  space  left  by  its  solution,  and  may  be  even- 
tually transformed  into  a  solid  cicatrix.  Sometimes  the  false 
membrane  is  formed  previously  to  the  detachment  of  the  eschar, 
and  serves,  in  fact,  to  separate  the  living  from  the  dead  parts. 
Pretty  often  there  is  no  false  membrane  at  all,  and  the  pus  (of.  a 
sanious,  grumous,  blackish,  greenish,  greyish. or  reddish  color, 
and  always  more  or  less  fetid,)  is  secreted  immediately  by  the 
walls  of  the  ulcer.  These  are  formed  of  a  tissue  which  is  usually 
dense,  and  firmer  and  drier  than  that  of  the  acute  pneumonia. 
It  creaks  under  the  scalpel ;  is  of  a  reddish  brown  color  verg- 
ing on  grey,  or  intermixed  with  shades  of  the  last  and  dirty 
yellow ;  and  exhibits  the  granular  aspect  on  the  incised  surfaces. 
This  state  of  engorgement,  which  evidently  constitutes  a  chronic 
pneumonia,  having  little  tendency  to  run  into  suppuration,  does 
not  commonly  extend  above  half-an-inch  or  an  inch  from  the 
excavation ;  occasionally,  however,  it  extends  to  the  whole  lobe 
in  which  it  is  situated.  At  other  times,  the  walls  of  the  excava- 
tion are  softish,  fungous,  and  in  such  a  state  of  putrid  decompo- 


GANGRENE    OF    THE    LUNGS. 


237 


sition  as  to  be  easily  destroyed  by  the  touch  of  the  scalpel. 
Pretty  large  blood  vessels,  naked  and  isolated,  but  still  sound, 
sometimes  traverse  these  excavations  ;  at  other  times,  the  vessels 
are  destroyed,  and  from  their  open  mouths  fill  the  cavity  with 
coagulated  blood.*  These  gangrenous  excavations  constitute 
the  ulcerous  phthisis  of  Bayle.  Although  he  does  not  exactly 
describe  their  origin,  the  account  which  he  gives  of  them  and  the 
cases  he  details,  show  that  he  suspected  it.  (Op.  Cit.  p.  30.  obs. 
xxv xxx.)  Perhaps  he  was  withdrawn  from  the  mode  of  inves- 
tigation which  would  have  led  him  to  their  real  origin,  by  the 
considerations,  which  (unreasonably  in  my  opinion)  led  him  to 
consider  this  as  a  species  of  phthisis.  Sometimes  the  gangrenous 
eschar,  in  a  state  of  decomposition,  makes  its  way  through  the 
pleura,  and  excites  a  pleurisy  usually  accompanied  by  pneumo- 
thorax, which  latter  appears  to  be  the  effect  of  the  gas  exhaled 
by  the  putrid  eschar.  At  other  times  the  gangrenous  excavation 
opens  at  once  into  the  pleura  and  bronchia  ;  and  from  the  latter 
is  derived  the  air  which  constitutes  the  pneumo-thorax. 

Physical  Signs.  These  are  almost  the  same  as  those  of  ab- 
scess of  the  lungs,  except  that  the  crepitous  rhonchus  is  not  so 
common  as  in  the  latter.  This  may  be  owing  to  the  insidious 
nature  of  the  disease,  which  does  not  lead  us  to  examine  the 
chest  during  the  first  days.  I  have  been  several  times  assured 
that  the  crepitous  rhonchus  did  not  exist  until  after  the  produc- 
tion of  the  eschar,  thereby  indicating  the  formation  of  the  inflam- 
matory circle  which  was  to  operate  its  detachment.  Subsequently, 
the  cavernous  rhonchus  is  perceived ;  and  when  the  excavation 
begins  to  empty  itself,  pectoriloquy  becomes  distinct.  When 
the  eschar  opens  into  the  pleura,  we  have,  further,  the  signs  of 
pneumo-thorax  combined  with  the  liquid  effusion ;  and,  if  it 
communicates  also  with  the  bronchi,  the  metallic  tinkling  or  the 
utricular  resonance  becomes  perceptible.  The  resonance  of  the 
voice  in  these  excavations  is  much  more  distinct  and  strong  than 
in  the  pulmonary  abscess:  it  has  nothing  of  that  floating  kind  of 
sound  of  the  latter,  and  is  rarely  accompanied  by  the  veiled  puff, 
so  common  in  the  abscess.  In  the  resolution  of  the  pneumonia 
which  succeeds  the  gangrene,  as  indeed  in  all  kinds  of  chronic 
pneumonia,  it  is  not  easy  to  detect  the  crepitous  rhonchus.  In 
this  affection  the  expectoration  is  so  characteristic  that  all  these 
signs  would  be  quite  insufficient  without  it.  It  is  sometimes 
green,  greenish,  or  brownish,  or  of  a  yellow  ash  grey  verging  on 
greenish,f  more  or  less  puriform,  and  with  the  gangrenous  fetor. 

*  Sec  a  msc  of  this  kind  recorded  in  M.  Cruvoilhier's  Mat.  Pathol.  Liv.  iii., 
in  which  the  gangrenous  excavation  communicated  with  the  sac  of  the  pleura, 
and  into  which  two  pints  of  blood  were  extravasated. — (M.  L.) 

i  The  reader  will  not  have  failed  frequently  to  remark  the  singular,  and,  as  it 


238  GANGRENE    OF    THE    LUNGS. 

In  the  beginning  of  the  disease  it  is  frequently  different.  It  has 
not  then  the  peculiar  fetor  of  gangrene,  although  it  has  a  fetor 
almost  as  insupportable.  Its  color  is  milk-white,  and  it  is  nearly 
opaque  and  of  the  consistence  of  mucilage.  Gradually  it  assumes 
a  greenish  yellow,  a  brownish  or  ash-color,  and  becomes  sanious 
or  purulent.  When  the  disease  becomes  chronic,  and  particu- 
larly when  it  is  in  progress  towards  a  cure,  the  sputa  become 
yellow  and  acquire  the  consistence  and  odor  of  pus.  From  time 
to  time,  however,  the  gangrenous  fetor  re-appears.  From  the 
result  of  several  cases  of  recovery,  I  am  tempted  to  believe  that 
the  fetor  and  aspect  of  the  expectoration  above  described,  do  not 
necessarily  indicate  the  existence  of  a  gangrenous  eschar  in  the 
lungs,  but  that  these  characters  may  depend  upon  a  general  dis- 
position to  gangrene,  manifesting  itself  especially  in  the  mucous 
secretion  of  the  bronchi.  We  might  indeed  suppose,  in  these 
cases,  the  existence  of  small  eschars  such  as  I  have  described  in 
Case  IV. ;  only  that,  in  two  or  three  dissections  which  I  have 
made  of  such  cases,  I  found  nothing  which  could  account  for  the 
gangrenous-  fetor,  unless  it  were  the  rapidity  with  which  the  body 
generally,  and  the  mucous  membrane  of  the  lungs  more  partic- 
ularly, ran  into  putrefaction. 

Symptoms  and  progress.  The  symptoms  of  the  partial  gan- 
grene of  the  lungs  are  extremely  variable,  and  differ  greatly  in 
the  different  periods  of  the  disease.  The  invasion  is  usually 
characterised  by  symptoms  of  slight  pneumonia ;  but  this  is  at- 
tended by  a  degree  of  prostration  of  strength  or  anxiety,  quite 
disproportioned  to  the  severity  of  the  local  symptoms,  and  to  the 
small  extent  of  space  over  which  the  respiratory  murmur  and 
sound  on  percussion  are  wanting.  In  a  short  time  the  patient 
begins  to  expectorate  sputa  which  are  only  at  first  disagreeable, 
but  soon  become  of  the  gangrenous  fetor.  At  the  same  time 
there  are  occasionally  very  severe  pains  in  the  chest,  and  likewise 
haemoptysis  more  or  less  abundant ;  and  the  patient's  complexion 
becomes  pale,  or  rather  wan  and  leaden.  Very  often  the  inva- 
sion of  the  disease  is  quite  insidious  ;  nothing  but  the  general 
debility  strikes  the  attention  of  the  physician,  and  nothing  seems 
to  announce  a  severe  affection  of  the  chest.  When  the  disease 
becomes  chronic,  there  is  a  constant  hectic  fever,  sometimes  con- 
siderable, but  usually  less  so  than  in  most  cases  of  phthisis  ;  the 
skin  is  hot,  and  the  expectoration  and  breath  fetid.     In  this  state, 

would  seem,  unnecessary  minuteness  of  our  author  in  his  description  of  colors; 
a  minuteness  which  is  only  to  be  paralleled  by  the  precision  of  my  most  excel- 
lent and  learned  friend,  Professor  Jameson,  in  his  mineralogical  definitions.  It 
is  scarcely  possible,  however,  to  follow  Laennec  in  some  of  his  minutiae;  al- 
though I  have  done  my  best  to  translate  them  faithfully,  even  while  doubting, 
sometimes,  if  I  could  recognize  the  subject  of  my  own  description  if  in  bodily 
presence  before  me. —  Transl. 


GANGRENE    OF    THE    LUNGS. 


239 


emaciation  is  very  rapid,  and  the  disease  may  readily  be  mistaken 
for  phthisis  ;  more  commonly,  however,  death  supervenes  before 
the  emaciation  has  made  much  progress,  the  disease  appearing 
rather  to  have  a  tendency  to  produce  cachexia  than  marasmus. 

However  dangerous  this  disease  may  be,  we  must  not  consider 
it  as  inevitably  fatal.  I  have  known  several  patients  recover  who 
had  all  the  symptoms  of  it;  and  some  of  these,  judging  from 
the  extent  of  the  pectoriloquy,  had  gangrenous  excavations  of 
great  size.  In  one  case  the  eschar  made  its  way  into  the  pleura, 
determining  a  pleurisy,  which  lasted  fifteen  months.  I  here 
subjoin  four  cases  of  gangrene  of  the  lungs ;  one  of  which  was 
communicated  to  me  by  M.  Cayol,  and  another  has  been  ex- 
tracted from  the  unpublished  manuscripts  of  Bayle. 

Case  XII.  Superficial  gangrenous  eschar  of  the  lungs  giving 
rise  to  pleurisy.  A  man,  aged  forty,  after  a  fit  of  intoxication, 
was  seized  with  head-ache,  pains  in  the  limbs,  fever,  and  deli- 
rium, and  was  in  this  state  admitted  into  the  Necker  Hospital 
on  the  28th  November,  1818.  At  this  time  he  only  complained 
of  pain  in  the  limbs.  There  was  general  fever,  and  at  night  there 
came  on  furious  delirium,  which  was  combatted  by  the  applica- 
tion of  twelve  leeches  to  the  throat,  ice  to  the  head,  and  sinap- 
isms to  the  thighs.  The  same  state  of  general  fever,  delirium, 
&c.  continued,  with  slight  variations  of  symptoms  and  treatment, 
until  he  died,  on  the  11th  December.  Two  days  before  his  death 
it  was  remarked  for  the  first  time,  that  the  respiration  was  some- 
what impeded,  and  was  found  by  the  stethoscope  to  be  less  dis- 
tinct on  the  right  side.  Percussion  yielded  an  equal  and  middling 
sound  on  both  sides. 

Dissection  twenty-four  hours  after  death.  The  brain  was  in 
a  natural  state.  There  was  some  serum  effused  in  the  ventricles, 
at  the  base  of  the  brain,  and  also  under  the  pia  mater.  The 
right  lung  adhered  anteriorly  to  the  costal  pleura  by  means  of 
a  recent  false  membrane,  and  its  base  was  united  to  the  dia- 
phragm by  a  similar  one.  The  middle  portion  of  the  lung  was 
compressed  towards  the  mediastinum  by  a  pint  and  a  half  of  a 
sero-purulent  fluid,  by  which  means  the  lung  was  reduced  to 
nearly  one  half  its  natural  size.  It  was  every  where  sound,  ex- 
cept that,  on  its  inferior  and  posterior  part,  there  existed  a  spot 
of  the  size  of  a  large  bean,  of  a  greenish-black  color,  and  ex- 
haling the  decided  gangrenous  fetor.  It  looked  like  an  eschar 
produced  by  the  application  of  caustic  potass,  but  it  was  humid 
and  so  soft  as  to  be  reduced  into  a  putrid  mass  by  scraping  with 
the  scalpel.  It  extended  about  six  lines  into  the  substance  of 
the  lung,  which  was  hepatized  to  the  distance  of  an  inch  around. 
The  left  lung  and  all  the  other  viscera  were  sound. 

Case  XIII.     (By  M.  Cayol) — Gangrene  of  the  lungs.     A 


240  GANGRENE  OF  THE  LUNGS. 

man,  aged  fifty-three,  came  into  La  Charite  on  the  16th  June, 
1811,  having  been  ill  six  weeks.  At  this- time  the  respiration 
was  oppressed,  and  there  was  frequent  cough  with  an  expectora- 
tion of  yellow,  opaque,  thickish  sputa,  having  a  gangrenous  fetor, 
which  was  however  still  more  offensively  marked  in  the  breath. 
The  chest  sounded  well  on  percussion.  From  the  beginning  of 
his  illness  this  man  had  experienced  a  daily  increasing  debility. 
He  was  not  however  much  emaciated,  but  his  flesh  was  soft  and 
his  complexion  very  wan.  The  same  symptoms  continued,  with 
gradual  increase,  until  his  death,  which  took  place  oh  the  20th 

July. 

Dissection  ten  hours  after  death.  The  thorax  sounded  well 
on  the  right  side,  and  was  preternaturally  sonorous  on  the  left, 
which  circumstance  made  M.  Bayle  predict  the  existence  of 
pneumo-thorax.  This  opinion  was  soon  confirmed  by  the  escape 
of  a  considerable  quantity  of  extremely  fetid  gas,  through  an 
opening  made  in  one  of  the  intercostal  spaces.  There  were  like- 
wise on  this  side  of  the  chest,  two  or  three  pints  of  blackish 
muddy  serosity  of  a  disgusting  fetor.  The  lung  was  of  a  black- 
ish color,  compressed  towards  the  mediastinum,  and  reduced  to 
one-fifth  of  its  natural  size.  In  its  upper  lobe  there  was  an 
irregular  excavation  large  enough  to  contain  a  duck's  egg.  The 
portion  of  lung  in  which  this  cavity  was  situated,  was  so  thin 
exteriorly  and  so  easily  torn,  that  we  doubted  whether  the  ca- 
vity might  not  have  been  produced  by  the  efforts  used  to  destroy 
the  adhesions.  M.  Bayle,  however,  thought  that  it  had  existed 
before  death.  This  excavation  was  filled  by  the  same  liquid 
which  occupied  the  pleura.  It  had  no  membranous  lining  of  any 
kind,  but  its  boundaries  consisted  of  the  naked  pulmonary  tissue, 
which  was  soft,  friable,  and  blackish.  There  were  many  lesser 
cavities  opening  into  this,  all  of  which,  as  well  as  the  principal, 
contained,  besides  pus,  insulated  masses  of  a  soft  putrid  sub- 
stance. That  contained  in  the  largest  excavation  was  of  the  size 
of  a  walnut.  These  masses  contained  blackish  filaments  resem- 
bling pulmonary  substance,  and  very  like  the  gangrenous  sloughs 
of  cellular  substance  found  in  certain  abscesses :  they  were,  no 
doubt,  eschars  detached  from  the  lungs.  There  were  adhesions 
in  various  parts  of  this  lung,  and  also  recent  false  membrane 
lining  a  large  portion  of  the  costal  pleura.  On  the  right  side  of 
the  chest  there  was  a  pint  of  reddish  and  limpid  serum ;  but  the 
lung  on  this  side,  and  all  the  other  viscera  were  sound. 

Case  XIV.  (By  M.  Bayle) — Partial  gangrene  of  the  lungs. 
A  man,  aged  forty-five,  had  been  affected  three  months  with 
coryza,  and  occasional  fever,  and  had  become  considerably  ema- 
ciated and  unfit  for  labor,  when  he  came  into  La  Charite  on  the 
15th  Oct.  1811.     At  this  period  the  patient  complained  only  ot 


GANGRENE    OF    THE    LUNGS. 


241 


stuffing  of  the  nose,  loss  of  appetite,  and  increasing  debility. 
He  had  a  slight  cough,  but  without  expectoration.  He  had  never 
spit  blood,  had  no  pain  of  the  chest,  lay  indifferently  on  either 
side,  and  had  no  other  impediment  in  respiration  but  what 
seemed  to  arise  from  the  nostrils.  It  being  supposed  that  he  had 
a  polypus,  he  was  transferred  to  the  surgical  wards,  where  he 
died  two  months  afterwards,  on  the  20th  Dec.  During  the  time 
he  was  in  the  surgical  wards,  his  cough  increased,  and  latterly 
the  respiration  was  much  oppressed,  and  he  had  also  a  severe 
pain  in  the  larynx,  which  induced  M.  Boyer  to  think  he  was 
affected  with  laryngeal  phthisis. 

Dissection.  The  larynx,  trachea  and  bronchi  were  sound  ;  as 
was  also  the  right  lung.  The  left  lung  was  dense  and  of  a  livid 
red  in  its  lower  portion,  being  in  a  state  of  engorgement  ap- 
proaching to  hepatization.  In  the  lower  part  of  the  inferior  lobe 
a  portion  of  the  pulmonary  substance  was  reduced  to  a  sort  of 
greyish  putrid  paste  having  the  gangrenous  fetor.  This  mass 
was  quite  continuous  with  the  surrounding  pulmonary  substance, 
which  was  red  and  engorged,  and  with  which  this  gangrenous 
spot  contrasted  both  as  to  color  and  consistence.  There  existed 
no  cavity  until  after  the  removal  of  the  gangrenous  clot.  This 
had  no  regular  shape,  nor  was  it  accurately  circumscribed :  it 
was  about  the  size  of  a  large  walnut.  The  rest  of  the  lung  was 
sound. 

Case  XV.  Pleurisy  and  pneumo-thorax,  consequent  to  the 
discharge  of  a  gangrenous  abscess  of  the  lungs.  A  man,  aged 
forty-two,  in  good  health  until  his  twentieth  year,  after  which  he 
labored  under  different  complaints  at  different  times — fever, 
severe  head-ache,  and  latterly  severe  pains  between  the  shoul- 
ders, for  which  he  was  repeatedly  in  ^ie  hospital — came  to  the 
Necker  Hospital  on  the  30th  May,  1818.  In  April,  his  pains 
ceased  after  taking  a  quack  medicine,  but  he  was  shortly  after 
seized  with  a  loss  of  appetite,  and  cough,  accompanied  by  a  co- 
pious and  extremely  fetid  expectoration.  The  following  is  the 
report  of  symptoms  on  admission :  moderate  lustiness,  skin 
brown,  decubitus  practicable  gii  both  sides,  but  easiest  on  the 
left ;  cough  frequent,  commonly  in  paroxysms,  expectoration 
rather  copious,  yellow  and  opaque  ;  respiration  very  good  on  the 
right  side,  much  less  perfect  on  the  left,  and  attended  by  a  mu- 
cous rhonchus  resonance,  on  percussion  somewhat  less  on  the 
left  side,  both  before  and  behind.  State  of  the  heart  natural. 
From  these  premises  the  diagnosis  was  given — Slight  chronic 
pneumonia  occupying  the  centre  of  the  left  lung.  The  same 
state  continued  until  the  7th  June.  At  this  time  the  respiration 
was  still  good  on  the  right  side  ;  but  on  the  left  it  was  only  per- 
ceptible at  the  roots  and  in  the  upper  lobe ;  in  the  latter  place  it 
31 


242  GANGRENE    OF    THE    LUNGS. 

was  more  distinct  than  before,  in  the  former  it  was  much  less 
distinct.  The  sound  on  percussion  on  this  side  was  also  less 
than  when  the  patient  came  into  the  hospital.  From  these  symp- 
toms I  made  the  following  addition  to  the  diagnosis : — the  pneu- 
monia begins  to  disperse  at  the  roots  of  the  lungs,  but  there 
has  supervened  pleurisy,  with  sero-purulent  effusion  in  the  left 
side.  On  the  12th,  respiration  was  just  perceptible  under  the 
left  clavicle ;  on  the  16th  it  was  hardly  perceptible  over  the  whole 
of  the  upper  half  of  this  side  anteriorly ;  but  the  sound  on  per- 
cussion was  now  particularly  clear  over  the  same  space.  I  there- 
fore subjoined  to  my  diagnosis — pneumo-thorax.  On  the  17th, 
the  pain  which  had  been  absent  since  April,  re-appeared  between 
the  fifth  and  sixth  ribs ;  the  other  symptoms  continued  nearly 
the  same.  On  the  3rd  July,  percussion  elicited  a  good  sound 
from  both  sides  of  the  chest  anteriorly  and  laterally.  The  sound 
of  respiration  was  good  on  the  right,  but  was  entirely  wanting 
on  the  left,  both  before  and  behind,  except  at  the  roots  of  the 
lungs  and  perhaps  a  litt'e  below  the  clavicle.  The  pain  in  the, 
back  was  more  severe ;  the  cough  was  also  more  violent,  and 
during  a  severe  fit  of  this  he  felt  an  acute  pain  in  the  left  side 
and  immediately  expectorated  about  half-a-pint  of  yellow,  opaque, 
somewhat  ropy  and  purulent  sputa ;  the  discharge  of  which 
seemed  at  once  to  relieve  and  weaken  the  patient.  The  expec- 
toration continued  copious  for  some  time.  During  several  ex- 
aminations the  state  of  the  chest  continued  nearly  the  same,  ex- 
cept that  respiration  was  very  slightly  audible  below  the  left 
clavicle,  and  the  left  back  yielded  a  duller  sound  on  percussion. 
The  patient  died  on  the  31st  July. 

Dissection  twenty-four  hours  after  death.  On  perforating 
with  the  scalpel  the  left* chest,  a  considerable  quantity  of  gas, 
having  the  fetor  of  gangrene,  made  its  escape.  The  left  lung 
was  compressed  towards  the  spine  and  mediastinum,  but  was 
united  at  its  anterior  edge  to  the  cartilages  of  the  ribs,  and  also 
to  the  mediastinum  and  back  part  of  the  ribs,  by  means  of  a 
membrane.  One-half  of  the  space  comprised  between  the  lung 
and  ribs  was  empty,  and  the  other  half  full  of  a  yellowish  semi- 
transparent  liquid,  purulent  at  bottom.  The  base  of  the  lung 
adhered  every  where  to  the  diaphragm,  except  over  a  small  space 
near  its  anterior  edge.  In  this  point  there  was  a  perforation, 
with  lacerated  blackish  borders,  which  would  have  admitted  a 
large  goose-quill.  The  black  color  extended  around  the  open- 
ing to  the  distance  of  two  or  three  lines,  marking  out  a  speck, 
which,  from  its  want  of  cohesion,  its  odor,  and  its  exact  cir- 
cumscription, had  all  the  characters  of  a  gangrenous  eschar. 
The  perforation  extended  from  four  to  six  lines  into  the  sub- 
stance of  the  lung,  and  then  terminated  in  an  excavation  capable 


GANGRENE    OF    THE    LUNGS. 


243 


of  containing  a  large  walnut.  The  walls  of  this  cavity  were  an- 
fractuous, and  lined  by  a  false  membrane  of  a  greyish-white, 
smeared  with  an  ash-colored  pus.  It  was  evidently  the  source 
of  the  gangrenous  fetor  perceived  on  opening  the  chest,  as  it  ex- 
haled this  odor  in  a  much  greater  degree.  Several  bronchial 
tubes  opened  into  it.  The  substance  of  the  lung  was  flabby, 
fleshy,  and  contained  little  blood  ;  it  was  firmer,  almost  hepatic, 
to  the  distance  of  half  an  inch  around  the  excavation  ;  the  bron- 
chi in  the  vicinity  of  this  were  greatly  dilated  :  several  of  them, 
naturally  of  the  size  of  a  crow-quill,  being  enlarged  to  the  diam- 
eter of  a  small  goose-quill :  their  lining  membrane  was  red,  and 
covered  with  a  sanious,  frothy  and  puriform  mucus.  The  right 
lung  and  the  other  viscera  were  healthy. 

Besides  the  idiopathic  kind  just  described,  there  exists  another 
species  of  circumscribed  gangrene  of  the  lungs,  that,  namely, 
which  occasionally  occurs  in  the  walls  of  a  tuberculous  excava- 
tion. This  is  an  extremely  rare  affection,  being,  at  least,  ten 
times  less  common  than  the  idiopathic  gangrene.  The  affection 
is,  however,  analogous  to  others  which  are  very  common  :  I  mean 
those  superficial  sloughings  which  take  place  in  cancers  of  the 
uterus,  stomach,  or  even  of  the  mamma.  When  a  tuberculous 
excavation  becomes  affected  in  this  manner,  its  walls,  to  the 
depth  of  one  or  two  lines,  are  converted  into  a  soft,  humid  eschar, 
of  a  greyish,  brownish,  greenish  or  blackish  color.  In  this 
slough  we  cannot  distinguish  the  grey  induration  which  usually 
surrounds  a  tuberculous  cavity,  but  we  may  perceive  any  crude 
tubercles  that  may  happen  to  be  there,  only  discolored  with  the 
matter  of  the  eschar.  This  becomes  soft  and  is  gradually  ex- 
pectorated ;  but,  as  in  the  case  of  the  idiopathic  gangrene  of  the 
lungs,  the  walls  of  the  excavation  continue  for  a  long  time,  after 
the  total  destruction  of  the  slough,  to  secrete  a  greyish  sanious 
pus  of  a  decidedly  gangrenous  fetor.  This  peculiar  odor,  to- 
gether with  the  greenish  or  greyish  color  of  the  expectoration, 
and  the  extreme  prostration  of  the  strength,  is  the  characteristic 
sign  of  this  species  of  pulmonary  gangrene,  as  well  as  of  the  pre- 
ceding. These  two  kinds,  however,  might  be  readily  distin- 
guished, if  we  had  an  opportunity  of  watching  the  progress  of 
the  disease  and  had  recognized  the  existence  of  pectoriloquy  pre- 
viously to  the  appearance  of  the  gangrenous  symptoms  * 

*  In  the  work  formerly  quoted  (Anat.  Path.  Hv.  iii.)  M.  Cruveilhier  gives  a 
case  which  he  considers  as  an  example  of  dry  and  non-fetid  gangrene  of  the 
lung.  In  this  case  the  left  upper  lobe  was  converted  into  avast  excavation  com- 
municating with  the  pleura,  yet  still  containing  a  white  and  odorless  pus ,  and  in 
this  there  was  a  detached  fragment  of  pulmonary  tissue.  The  patient  had  lived 
thirty-five  days  after  the  invasion  of  the  disease  ;  the  chief  symptoms  were  se- 
vere dyspnoea  and  repeated  haemoptysis  ;  and  the  matter  expectorated  was,  by 
turns,  mucous,  puriform,  sanguineous,  reddish,  and  icithout  fetor.  From  the 
symptoms  and  appearances  after  death,  I  am  disposed  to  refer  this  remarkable 
excavation  to  the  softening  and  separation  of  an  apoplectic  mass. — (M.  L) 


244  CHRONIC    PNEUMONIA. 


Sect.  IV. — Of  chronic  pneumonia. 

Is  there  really  such  a  disease  as  chronic  pneumonia  ?  This 
question  will  only  appear  singular  to  those  who  arc  practical}}' 
unacquainted  with  pathological  anatomy.  And  the  fact  certainly 
is,  that  data  for  its  right  determination  can  be  supplied  neither 
by  ancient  nor  modern  writers.  If  we  consider  the  question  a 
■priori,  it  seems  hardly  probable  that  an  organ  so  vascular,  so 
mobile,  and  so  essential  to  life  as  the  lungs,  can  remain  long  in 
such  a  state  of  slow  and  inactive  inflammation,  as  we  know  to  be 
frequently  the  condition  of  organs  less  necessary  to  life.  Ac- 
cordingly, we  find  that  those  excellent  observers  of  nature,  the 
Greeks,  have  made  no  mention  of  chronic  pneumonia  ;  and  the 
term  is  hardly  to  be  met  with  in  the  schools  of  more  modern 
times,  although  it  must  be  confessed  that  these  have  been  too 
much  in  the  habit  of  delineating  diseases  after  a  preconceived 
theory.  If  any  physicians  of  the  present  day  in  Paris,  still  make 
use  of  this  phraseology,  they  apply  it,  in  imitation  of  schools,  the 
most  ignorant  of  pathology,  to  phthisis  pulmonalis,  which  they 
affect  to  consider  as  one  of  the  terminations  of  pneumonia.  This 
is  the  opinion  of  M.  Broussais,  (I)oct.  Med.  t.  ii.  passim.)  who 
even  appears  to  consider  it  as  novel :  we  shall  hereafter  find  how 
groundless  it  is. 

I  am  acquainted  with  only  a  small  number  of  cases  which  can 
be  considered  as  examples  of  chronic  pneumonia ;  and  they  are 
extremely  rare.  As  I  have  stated  in  the  preceding  section,  I 
have  occasionally  found  the  pulmonary  substance  around  a  gan- 
grenous excavation,  much  harder  than  in  simple  hepatization,  and 
creaking  under  the  scalpel.  The  incised  surfaces  in  this  case 
have  the  granular  appearance  more  marked  than  in  the  acute 
pneumonia.  This  appearance  is  still  more  distinct  when  we 
tear  the  morbid  part ;  the  granulations  being  more  obvious, 
much  firmer  and  drier,  and  very  much  like  the  eggs  of  certain 
insects,  which  are  closely  pressed  together  without  any  interme- 
diate substance.  The  cut  surfaces  have  the  various  coloring 
which  is  observed  in  the  acute  hepatization  ;  but  the  violet  grey 
and  the  livid  red  are  the  predominating  hues.  We  can  distin- 
guish very  few  points  of  yellow ;  but  sometimes  we  observe  a 
distinct  greenish  shade,  the  result  of  the  gangrene  previously  ex- 
isting in  the  vicinity.  The  diseased  parts  are  hardly  at  all 
humid,  and  even  yield  scarcely  any  kind  of  fluid  when  scraped 
by  the  scalpel.*     I  have  noticed  a  similar  condition  of  parts  after 

*  This  statement  appears  to  me  incorrect.  The  indurated  pulmonary  tissue- 
which  surrounds  gangrenous  masses,  far  from  being  dry,  is  usually  bo  humid  as 
to  be  cedematous. — (M.  L.) 


CHRONIC    PNEUMONIA. 


245 


an  haemoptysis,  which  has  been  succeeded  by  a  slight  pneumonia 
of  several  weeks'  duration.  We  at  times  observe  something  of 
the  same  kind,  but  very  rarely  and  indistinctly,  around  large 
tuberculous  excavations,  and  in  the  small  interspaces  in  cases  of 
numerous  tubercles ;  but  in  botli  these  examples  it  is  much  more 
common  to  find  the  marks  of  an  acute  hepatization,  which  had 
occurred  only  a  few  hours  before  death.  In  instances  of  this 
sort,  we  must  be  careful  not  to  confound  the  condition  of  parts 
described,  with  the  grey  tuberculous  induration,  common  in 
lungs  filled  with  tubercles,  and  which  is  only  one  of  the  forms 
of  these  accidental  productions :  the  tuberculous  induration  is 
semi-transparent,  vitriform,  and  humid,  and  the  incised  surfaces 
are  smooth  and  homogeneous. 

We  may  also  term  those  cases  chronic,  in  which  the  pneu- 
monia, although  originally  acute,  has  been  checked  in  its  pro- 
gress by  blood-letting  or  other  antiphlogistic  means,  but  in  which 
these  antiphlogistic  means  have  been  insufficient  to  procure 
speedy  resolution,  or  even  to  prevent  relapses.  I  have  known 
instances  of  this  kind  continue  two  months  in  the  stage  of  en- 
gorgement, and  finally  terminate  in  simple  oedema  before  being 
cured.  In  other  examples,  in  addition  to  the  engorgement,  there 
existed  some  spots  in  a  state  of  hepatization.  1  have  even 
known  abscess  of  the  lungs  occur  in  this  chronic  stage  of  the  dis- 
ease. Cases  of  this  kind  seldom  prove  fatal ;  but  in  the  small 
number  in  which  I  have  been  able  to  examine  the  body  after 
death,  I  have  found  different  parts  of  the  lungs,  here  and  there, 
of  a  firmer  consistence,  and  drier  than  in  the  acute  hepatization, 
but  in  other  respects  quite  similar.  In  the  intervals  of  these 
portions,  the  pulmonary  substance  was  loaded  with  serosity  con- 
taining small  specks  of  pus,  rather  suspended  than  dissolved,  and 
which,  as  well  as  the  yellowish  hue  of  the  lungs,  seemed  to  me 
to  point  out  the  resolution  of  a  case  of  pneumonia  which  had 
reached  the  stage  of  suppuration.* 

*  The  statements  contained  in  this  section  will,  no  doubt,  appear  singular  to 
many  English  readers ;  and  I  confess,  that  ii  I  felt  justitied  in  placing  the  dissec- 
tions made  in  this  country  (including  my  own)  on  the  same  level,  as  to  minute- 
ness and  accuracy,  as  those  made  by  the  French  pathologists,  I  should  feel  dis- 
posed to  question  the  truth  of  these  statements.  But  as  every  candid  person 
must  admit  that  the  hurried  manner  in  which  dead  bodies  are  commonly  exam- 
ined in  this  country  (or  used  to  be  so,  at  least.)  renders  mistakes  extremely 
probable  ;.and  as  we  must  likewise  confess  that  our  means  of  observation,  and 
consequently  our  experience,  fall  vastly  short  of  theirs,  it  is  perhaps  no  great 
Stretch  of  candor  to  be  willing  to  receive  the  authority  of  such  men  as  Laennec 
Chomel,  Andral,  and  Louis,  in  preference  not  only  to  many  of  our  recorded 
cases,  but  even  to  our  own  hurried  observation.  The  correctness  of  our  author"s 
statement  respecting  the  great  infrequency  of  pneumonia  in  a  chronic  form,  is 
supported  by  the  concurring  testimony  of  the  most  experienced  pathologists  of 
the  present  French  school.  Andral  says,  that  of  one  hundred  and  twelve  cases 
observed  by  him,  only  one   lasted  more  than  thirty  days;  and  that  daring  the 


246  LATENT    PNEUMONIA. 


Sect.  V. — Of  latent  and  symptomatic  pneumonia. 

When  we  consider  the  importance  of  the  organ  affected,  and 
the  serious  mischief  produced  by  the  disorder  of  its  functions,  we 
might  suppose  pneumonia  to  be  one  of  those  diseases  which  could 
with  the  greatest  difficulty  escape  detection.  Nevertheless,  we 
have  already  shown,  that  the  severest  instances  of  simple  inflam- 
mation of  the  lungs,  are  sometimes  recognized  with  difficulty 
during  the  first  days  of  the  attack  ;  but  it  is  when  complicated 
with  another  disease,  that  pneumonia  most  easily  escapes  the 
notice  of  the  practitioner.  I  shall,  therefore,  proceed  to  point 
out  the  complications  which  are  most  common,  and  most  likely 
to  mislead.  I  will  not,  however,  notice,  in  this  place,  the  com- 
bination with  pleurisy,  as  that  will  form  the  subject  of  a  distinct 
section.     We  have   already  seen  that  pneumonia  is  sometimes 

five  years  which  he  had  been  at  La  Charite,  he  had  mot  with  very  few  examples 
of  hepatization  or  purulent  infiltration,  in  cases  of  more  than  two  months' 
standing.  (Med.  Clin.  t.  ii.  p.  365.)  M.  Chomel  states,  (Diet,  de  Med.  t.  xvii. 
p.  252,)  that  in  the  course  of  the  last  sixteen  years,  during  which  he  has  exam- 
ined, on  an  average,  two  hundred  dead  bodies  annually,  he  has  only  met  with 
two  well-marked  cases  of  this  affection.  Andral  notices  it  as  existing  under 
two  forms,  the  grey  and  red  induration,  and  describes  it  briefly  as  being  dry  and 
hard,  of  a  pale  red  or  greyish.  (Op.  Cit.  p.  310.)  Chomel  describes  the  lesion 
in  the  two  cases  met  with  by  him,  as  consisting  of  a  grey  dense  induration, 
without  granulations,  much  dryer  and  harder  than  hepatization,  and  occupying 
a  fourth  or  fifth  part  of  one  lung.  The  same  condition  of  lung  is,  I  think, 
described  by  Corvisart,  in  his  Commentary  on  Avenbrugger,  p.  287,  and  by 
Avenbrugger  himself,  p.  262,  and  appears  to  be  that  found  by  myself  in  the  case 
of  chronic  pleurisy,  detailed  in  "  Original  Cases,"  p.  247.  M.  Andral  likewise 
considers  that  black  induration  of  the  lungs,  sometimes  existing  around  tuber- 
culous excavations,  and  which  Laennec  describes  as  a  particular  degeneration 
under  the  name  of  melanosis,  as  being  frequently  the  result  of  chronic  inflam- 
mation. (Op.  Cit.  iii.  p.  230.)  In  the  small  work  above  mentioned,  I  have 
entitled  several  observations  "chronic  pneumonia;"  and  I  certainly  have  been 
in  the  habit  of  considering  many  cases  I  met  with  in  practice  as  examples  of 
this  disease.  I  am  willing  to  admit,  however,  that  I  have  been  sometimes  mis- 
taken, and,  both  in  practice  and  in  my  dissections,  have  confounded  different 
affections  under  this  name. 

The  truth  seems  to  be,  that  inflammation  of  the  pulmonary  substance,  strictly 
and  essentially  chronic,  (like  the  chronic  affection  of  the  serous  membranes,)  is 
extremely  rare  ;  but  that,  as  a  sequel  of  the  acute  disease  imperfectly  resolved, 
or  as  complicating  other  organic  lesions  of  the  lungs,  it  is  by  no  means  uncom- 
mon. Our  author  himself  admits  that  the  acute  disease,  made  chronic  by  treat- 
ment, may  last  two  months;  and  Lorinser  says  that  this  period  may  be  doubled. 
Both  M.  Andral  and  M.  Chomel,  however,  arc  of  opinion  that  chronic  inflam- 
mation of  the  pulmonary  substance  is  very  common  under  another  name  and 
form.  They  consider  the  thin  layer  of  grey  substance  which  is  found  surround- 
ing softened  tubercles  (and  which  Laennec  regards  as  simply  tuberculous)  to  be 
the  product  of  chronic  inflammation.  In  this  opinion  they  are  joined  by  Louis 
(Rccherches,  p.  9.)  For  further  observations  on  this  subject,  see  the  chapter 
on  phthisis  in  the  present  work. 

Chronic  pneumonia  is  not  indicated  by  any  peculiar  physical  signs,  presenting 
those  only  of  obstruction  or  induration  of  more  or  less  of  the  pulmonary  tissue, 
viz.  dullness  on  percussion,  absence  of  the  respiratory  murmur,  and  the  develop 
ment  of  bronchophony  and  bronchial  respiration.—  Transl. 


LATENT    PNEUMONIA. 


247 


conjoined  with  haemoptysis:  it  still  more  frequently  supervenes 
to  oedema  of  the  lungs.  The  sero-sanguineous  congestion  of  the 
lungs,  which  takes  place  in  almost  all  dying  persons,  is  frequently 
converted  into  pneumonia,  if  the  agony  is  at  all  protracted.  On 
examination  after  death,  different  points  of  the  lungs  are  found 
distinctly  hepatized,  more  particularly  during  the  prevalence  of 
an  inflammatory  constitution*  This  species,  which  I  term  pneu- 
monia of  the  dying,  is  commonly  accompanied  with  a  very  strong 
and  suffocating  tracheal  rhonchus ;  but  the  presence  of  the  rhon- 
chus  does  not  always  indicate  the  existence  of  this  disease.  This 
rhonchus,  when  extremely  strong,  is  unquestionably  the  thing 
most  apt  to  mask  the  crepitous  rhonchus  of  incipient  pneumonia. 
Andral  encountered  this  difficulty,  and  would  seem  to  consider  it 
as  insurmountable  (Op.  Cit.  p.  235,  &c.)  ;  but  I  am  of  opinion 
that  attention  and  experience  will  always  enable  us  to  distinguish 
the  crepitous,  amid  the  loudest  mucous  rhonchi.  I  have  never 
experienced  any  difficulty  in  this  respect,  except  where  the  case 
was  rather  the  cessation  of  life  than  a  formal  disease,  or  where 
the  engorged  portion  of  lung  was  very  small.f — Pneumonia  is 
occasionally  combined  with  the  different  varieties  of  catarrh,  but 
more  rarely  perhaps  than  with  any  other  disease  of  the  chest.  It 
is  by  no  means  common  to  find  the  acute  catarrh  terminate  in  pneu- 
monia ;  and  in  the  instances  of  epidemic  pneumonia,  persons 
affected  with  chronic  mucous  or  pituitous  catarrhs,  are  perhaps 
less  liable  to  be  attacked  than  those  who  are  in  perfect  health. 
The  rule  is,  however,  not  without  exceptions.  The  suffocative 
catarrh,  particularly  when  it  attacks  young  persons  or  adults,  is 
often  complicated  with  pneumonia ;  and  we  meet  with  indivi- 
duals habitually  subject  to  chronic  catarrh,  commonly  dry,  (but 
becoming  occasionally  mucous,)  who  are  extremely  liable  to  be 
attacked  by  this  disease  from  the  slightest  causes,  and  who  have 
two  or  three  seizures  in  the  course  of  the  year. — Phthisical  sub- 
jects are  liable  to  attacks  of  pneumonia,  usually  of  small  extent, 
and  the  symptoms  of  which  are,  therefore,  very  readily  con- 
founded with  those  of  the  primary  disease.  On  this  account,  if 
for  no  other  reason,  it  is  important  to  explore,  from  time  to  time, 
the  chest  of  consumptive  patients,  more  particularly  when  there 

*  Louis  states  (Recherches,  p.  39,)  that  out  of  one  hundred  and  twelve  sub- 
jects, who  died  of  various  chronic  diseases,  he  found  the  lungs  partially  inflamed 
in  the  first  degree  (engorged)  in  ten,  and  in  the  second  degree  (hepatized)  in 
twelve.  In  all  these  cases  he  says  that  it  was  evident  the  inflammation  had  su- 
pervened only  a  few  days  before  death. —  Transl. 

t  Notwithstanding  the  assertion  of  Laennec,  I  still  believe  that  in  cases 
where  there  is  a  noisy  mucous  rhonchus,  like  the  one  here  described,  ausculta- 
tion cannot  possibly  reveal  the  existence  of  pneumonia,  unless  the  disease  be 
sufficiently  violent  to  give  rise  to  the  bronchial  murmur;  this  is  often  heard 
through  the  bubbles  of  the  mucous  rhonchus,  especially  when  the  patient  is 
made  to  breathe  hard. — Andral. 


248  LATENT    PNEUMONIA. 

is  any  increase  of  fever,  or  any  sudden  decrease  of  strength.* — 
Several  diseases  which  may  be  considered  of  a  general  kind,  have 
a  singular  tendency  to  be  complicated  with  pneumonia,  or  to  ex- 
cite this  affection   sympathetically.     It  is  thus  found  occasionally 
to  supervene  to  an  attack  of  gout  or   rheumatism.     If  the  pains 
of  the  limbs  cease  on  its  attack,  it  is  usually  recognized,  or  at 
least  suspected,  from  obvious  symptoms  ;  but  if  the  pains  continue, 
the  pulmonary  affection  remains  latent,  or  is  only  discovered  by 
means  of   an   attentive  exploration.      The  eruptive   fevers   are 
sometimes   combined  with    pneumonia.     Measles,  in   particular, 
frequently  present  this  union,  at  the  period  of  the  disappearance 
of  the  eruption.     In   this  case  the  pneumonic  affection  is  pretty 
frequently  manifest ;  but  when   it  supervenes  in   the  course  of 
confluent  small-pox,  or  severe    erysipelas,  it   is    almost  always 
latent.     The  same  is  true  of  the  pneumonia  which  arises  in  the 
course  of  violent  continued  fevers.     Nothing   is  more  common 
than  this  last-named  complication,  especially  in  winter  and  during 
the  prevalence  of  pneumonia ;  and  in  these  cases,  its  invasion  is 
seldom  indicated  by  any  unusual  dyspnoea   or  expectoration,  or, 
in  short,  by  any  of  the  ordinary  symptoms  of  inflammation  of  the 
lungs.     It  is  true  that  it  only  occurs  towards  the   fatal  termina- 
tion of  the   disease  ;  but  probably  it  is   also  very  often  the  cause 
of  this.     In  the  young  and  robust,  the  invasion  of  the  pneumonia 
may  sometimes  be  suspected  from  a  marked  increase    of  fever 
taking  place.     But  in  old  persons,  and  in   subjects  weakened  by 
the  long  continuance  of  high   fever  and  low  diet,  it  comes  on  all 
at  once,  attended  by  a  sudden  prostration  of  strength  and  loss  of 
consciousness.     The  skin   becomes  harsh,   the  excretions  fetid, 
the  teeth  and  tongue  covered  with  a  fuliginous  coating,  and  coma 
or  the  tracheal  rhonchus  announces  the  approach  of  death.  These 
latter  symptoms   frequently  indicate  the    supervention   of  pneu- 
monia in  subjects  worn  out  by  severe    chronic  disease,  especially 
cancer.      We  ought   to  range    among. sympathetic    pneumonies 
that  which   constitutes  the  predominant  symptom  in  the  perni- 
cious fevers  denominated  pneumonic.     The  morbid  anatomy  of 
this   affection    is  yet  very  imperfectly  known,   from    the  circum- 
stance of  its  proving  rarely  fatal ;    as  we  fortunately  possess  in 

*  Andral  describes  the  intercurrent  pneumonia  of  phthisical  subjects  as  being 
very  common,  and  as  often  occasioning  death,  from  being  overlooked.  In  the 
acute  form  it  is  remarkable  for  its  frequent  occurrence  in  the  same  subject,  it 
being  by  no  means  uncommon  to  find  the  same'patient  affected  with  it  twelve  or 
fifteen  times.  (CI.  M.  iii.  225.)  Louis  (Rech.  p. 241)  while  he  admits  the  occur- 
rence of  this  complication  with  phthisis  in  the  early  stages,  (w  hen  it  is  most  com- 
monly cured.)  notiees  it  chiefly  as  supervening  towards  the  very  last  days  of  the 
disease.  At  this  time  it  is  very  frequent,  vet  be  says  not  more  so  than  in  other 
persons  dying  of  chronic  affections;  (see the  preceding  note  ;)  so  that  he  con- 
ceives himself  justified  in  stating  that  phthisis  in  its  latter  stages,  has  no  particu- 
lar influence  in  exciting  pneumonia. —  Transl. 


LATENT    PNEUMONIA. 


249 


cinchona,  when  administered  in  time,  a  certain  means  of  cure. 
We  hqve  some  facts,  however,  which  prove  that  traces  of  pneu- 
monia have  been  found  in  subjects  dead  of  this  disease  ;  I  have 
myself,  in  two  accessions  of  this  fever,  witnessed  the  presence  of 
the  glutinous  sputa,  and  a  very  intense  crepitous  rhonchus.* 

Sect.  VI. — Treatment  of  pneumonia. 

Pneumonia,  in  common  with  the  whole  class  of  inflammatory 
affections,  seems  to  be  one  of  those  diseases  in  which  the  indica- 

*  A  very  important  variety  of  pulmonic  inflammation,  important  no  less  from 
the  causes  which  give  occasion  to  it  than  from  its  peculiar  characters,  has  been 
lately  introduced  to  the  notice  of  the  profession  by  some  of  our  distinguished 
surgical  pathologists  :  I  allude  to  that  which  supervenes  to  wounds  and  the  lar- 
ger operations,  and  which  is,  I  fear,  too  often  latent.  See  Guthrie's  Treatise  on 
Gunshot  Wounds,  (first  published  in  1815,)  2nd  Ed.  p.  284  :  and  C.  Bell's  Sur- 
gical Observations,  Part  iii.  p.  241.  Lond.  1817.  From  the  statements  made  by 
these  authors,  it  appears  that  pneumonia  is  a  very  frequent  cause  of  death  in  the 
cases  in  question  ;  and  that  it  comes  on  in  the  most  insidious  manner,  scarcely 
giving  warning  of  its  presence,  certainly  not  of  its  violence,  until  too  late  for 
beneficial  treatment.  In  these  cases  I  would  strongly  recommend  the  stetho- 
scope to  the  surgical  practitioner,  as  a  sure,  and  almost  exclusive,  means  of  ac- 
quiring an  exact  knowledge  of  the  progress  of  the  disease.  From  the  account 
given  of  it  by  M.  Guthrie  and  Sir  C.  Bell,  it  appears  evident  to  me,  that  had  this 
instrument  been  applied  on  the  first  appearance  of  the  dyspnoea,  the  crepitous 
rhonchus  would  have  immediately  pointed  out  the  presence  of  the  inflammation, 
of  which  the  general  symptoms'gave  little  or  no  indication,  and  might  have  there- 
by been  the  means  of  checking  its  fatal  progress  by  suggesting  the  proper  rem- 
edies. At  the  same  time  that  I  state  this,  1  am  not  ignorant  that  cases  occur, 
(though  very  rarely)  so  completely  latent  as  not  only  to  be  unaccompanied  by 
dyspnoea,  cough,  or  expectoration,  but  even  to  yield  no  results  from  percussion 
or  auscultation.  (See  Andral,  t.  ii.  p.  369.)  The  reason  of  the  lungs  becoming 
affected  in  the  class  of  cases  just  noticed,  is  an  interesting  subject  of  inquiry, 
but  one  on  which  I  cannot  here  enter.  It  is,  however,  very  doubtful  if  many 
of  the  purulent  depositions  found  in  the  lungs  after  operations  and  certain  dis- 
eases which  give  rise  to  unhealthy  inflammation  and  phlebitis,  are,  in  reality, 
the  consequence  of  any  preceding  phlogosis  of  the  pulmonary  tissue.  They 
would  certainly  seem,  in  some  cases,  to  be  rather  the  result  of  a  metastasis  or 
transposition  of  pus  from  a  remote  part. 

Cases  of  latent  pneumonia  had  not  escaped  the  notice  of  that  most  excellent 
writer  J.  P.  Frank.  "  Est  tamen  (he  says)  ubi  in  thoracis  cavo  occulta  viscerum 
inflammatio  latuit;  cui  signa,  cum  vivefet  segrotans,  defuere  quidem ;  sed  ubi 
•lira  inflaminatio,  vel  facta  jam  pulmonis  suppuratio,  post  mortem  demum  in  con- 
spectum  venetunt.  Eadem  in  pluribus  accidisse  vaccis observavimus,  quas,  cum 
epidemica  summeque  lethalis  has  bgstias prosequeretur  peripneumonia;  vel  cum 
-anions  apparerent,  experiment]  causa  niactatas,  cum  duro  ac  inflammato  pul- 
mone  secuimus."  De  Cur.  Horn.  Morb.  lib.  ii.  p.  135.  For  some  account  of 
this  disease  among  cattle  by  Lorinscr,  see  his  Lungenkrankheiten,  p.  212,  and 
also  Bojanus's  •■  Anleitung  zur  kenntniss  und  behandlung  der  wichtigsten  seuchen 
unter  den  Hausthieren."  Berlin,  1S20,  p.  165.  Lorinser  states  that  in  these 
cases,  the  lungs  are  found  hepatized,  to  a  greater  or  less  extent;  and  upon  com- 
paring the  size  and  weight  of  the  diseased  and  healthy  organ,  he  is  convinced 
thai  the  lungs  are  (as  Broussais  maintains)  actually  enlarged  in  pneumonia.  He 
-ays.  that  he  found  the  diseased  lnn«s  weighing  from  twenty-five  to  thirty  pounds, 
being  an  increase  of  from  twenty-two  to  twenty-seven  pounds  above  the  weight 
of  the  sound  viscus.  For  some  valuable  observations  on  symptomatic  affections 
of  the  lungs,  and  other  organs  in  surgical  cases,  I  refer  to  a  recent  paper  by  Mr- 
Rose  in  the  14th  vol.  of  the  Med.  Chu    Trans. —  Transl. 

32 


•250  TREATMENT    OF    PNEUMONIA. 

tions  of  treatment  are  the  most  obvious.  And  yet  if  we  seek  to 
establish  this  on  any  particular  theory,  we  shall  find  that  the 
most  opposite  measures  have,  in  their  turn,  been  held  up  to  ex- 
clusive commendation.  On  this  account  I  shall  here  content 
myself  with  giving  an  exposition  of  the  results  of  observation 
relative  to  the  chief  methods  of  treatment  hitherto  proposed. 

Bloodletting.  From  the  time  of  Hippocrates  to  the  present 
day,  most  medical  men  have  regarded  pneumonia  as  one  of  the 
diseases  in  which  bloodletting  is  productive  of  the  most  striking 
benefit.  To  this  general  truth  all  good  practitioners  have  ad- 
mitted only  a  few  general  exceptions ;  and  it  has  only  been  by 
some  few  theorists  and  medical  heretics  that  its  employment  has 
been  proscribed.  The  same  uniformity  of  opinion,  however, 
has  not  existed  respecting  the  quantity  of  blood  to  be  drawn  at 
one  time,  the  period  of  the  disease  when  bloodletting  ceases  to 
be  useful,  and  the  part  of  the  body  where  it  ought  to  be  per- 
formed. The  greater  number  of  the  ancient  physicians  bled 
only  at  the  onset  of  the  disease,  and  allowed  the  blood  to  flow 
until  syncope  took  place.  This  practice  was  sometimes  followed 
even  by  Galen.  It  was  much  used  in  the  century  before  the  last. 
It  is  still  very  common  in  England  ;  many  of  the  physicians  of 
that  country,  in  the  commencement  of  pneumonia,  directing  the 
detraction  of  twenty-four,  thirty,  or  thirty-six  ounces  of  blood. 
This  practice  is  not  to  be  found  fault  with  ;*  since  it  is  certain 

*  After  the  matter  of  fact  statement  in  the  latter  part  of  this  sentence,  it  is  no 
wonder  that  our  author  goes  the  length  of  admitting  that  the  English  practice  of 
bleeding  largely  in  the  beginning  of  pneumonia  "is  not  to  be  found  fault  with." 
But  it  is  truly  wonderful  that  after  such  a  statement,  he  does  not  recommend  the 
practice  in  preference  to  that  commonly  followed  by  most  continental  practi- 
tioners, and  which  is  detailed  in  the  next  page.  To  the  readers  of  this  work  it 
is  unnecessary  to  say,  that  the  quantity  of  blood  mentioned  in  the  text  may  be 
detracted  twice  or  even  thrice  within  the  period  of  twenty-four  hours,  in  the 
beginning  of  the  disease,  not  only  with  safety,  but  unquestionable  benefit, — due 
consideration  being  had  to  the  severity  of  the  attack,  the  constitution  of  the 
patient,  and  the  character  of  the  prevailing  epidemic.  It  is  only  in  the  more 
advanced  stages  of  the  disease,  that  greater  caution  is  necessary  in  the  detrac- 
tion of  blood  ;  and  it  is  the  prosecution  of  the  same  vigorous  treatment  at  this 
latter  period,  too  common  in  this  country,  that  is  justly  obnoxious  to  the  criticism 
of  foreign  practitioners.  In  such  circumstances,  there  can  be  no  doubt  that  the 
small  bleedings  and  copious  leechings  used  abroad  are  vastly  preferable  ;  or  even 
the  expectant  system,  with  its  starvation  and  its  innoxious  ptisans.  The  system 
of  medical  practice  in  this  country  is  perhaps  too  generally  chargeable  with  the 
imputation  of  overactivity  ;  the  medicina  perturbatrix  is  too  exclusively  cultiva- 
ted, especially  by  the  younger  members  of  the  profession.  Poor  nature  with 
her  vis  medicatrix  is  so  scorned  and  outraged,  in  what,  after  all,  is  truly  her 
own  dominion,  that  it  is  no  wonder  if  the  acts  of  such  radical  reformers  of  her 
plans  are  sometimes  turned  to  their  own  confusion.  I  believe,  however,  that  the 
unlimited  intercourse  now  happily  existing  among  the  nations  of  Europe,  is  gra- 
dually improving  the  medical  practice  of  each  individual  country.  This  is  obvi- 
ous in  respect  to  bloodletting  in  pneumonia.  M.  Andral  in  his  late  work  says, 
that  the  first  bleeding  should  be  from  sixteen  to  twenty  ounces-,  and  that  the  op- 
eration may  be  repeated  twice  or  even  thrice  within  the  first  twenty-four  hours 
(Op.  Cit.  torn.  ii.  p.  379.)     M.  Chomel  also,  in  his  article  on  pneumonia  in  the 


TREATMENT    OF    PNEUMONIA. 


251 


that  a  copious  bleeding  in  the  beginning  of  the  disease,  reduces 
the  inflammatory  orgasm  much  more  speedily,  than  repeated 
smaller  venesections  will  do  at  a  later  period,  and,  moreover, 
leaves  less  chance  of  a  renewal  of  the  inflammation.  The  ancients 
considered  bleeding  as  a  questionable  remedy  after  the  first  days 
of  the  disease,  fearing  thereby  to  check  the  expectoration ;  and 
the  best  practitioners  of  the  two  last  centuries  forbad  this  opera- 
tion after  the  fifth  day,  if  the  discharge  was  mucous  and  abun- 
dant. Apprehensions  of  this  kind  are  not  perhaps  unreasonable, 
if  the  loss  of  blood  is  carried  to  syncope  ;  but  we  know  from 
experience,  that  in  a  lesser  degree,  though  still  pretty  copious, 
bloodletting  may  be  had  recourse  to  with  much  advantage,  in  a 
very  advanced  period  of  pneumonia,  even  when  this  has  reached 
the  suppurative  stage  and  is  attended  with  a  great  expectoration.* 

Diet,  de  Med.  (torn.  xvii.  p.  243,)  says,  that  the  first  bleedings  should  be  from 
twelve  to  sixteen  ounces,  and  that  one  may  be  repeated  a  few  hours  after  anoth- 
er, to  the  third  time  on  the  same  day.  In  a  recent  journal,  (La  Clinique,  torn.  i. 
No.  20,)  bleedings  of  from  two  to  three  pounds  repeated  every  twelve  hours,  are 
strongly  recommended  by  M.  Renauldin.  For  some  excellent  remarks  on  the 
propriety  of  instituting  one  very  copious  bleeding,  in  the  early  stage  of  pneumo- 
nia, I  refer  the  reader  to  a  paper  by  Dr.  Robertson  in  the  Edin.  Journ.  vol.  x.  p. 
,  192.  The  aphorism  of  Dr.  Gregory  there  quoted — "  the  danger  of  a  large  bleed- 
ing is  less  than  the  danger  of  the  disease" — is  excellent;  and  it  were  well  if  it 
were  more  frequently  in  the  recollection  of  practitioners,  in  the  beginning  of  in- 
flammatory diseases.  Without  at  all  sanctioning  the  practice  therein  detailed, 
I  would  also  refer  the  reader  to  a  singular  document  in  the  same  journal  (vol. 
xiii.  p.  165)  for  proofs  of  the  astonishing  extent  to  which  bloodletting  may  be 
carried  with  safety  at  least,  if  not  with  benefit.  The  writer,  Mr.  Com rie,  states, 
that  his  practice  (the  disease  was  the  ardent  fever  of  the  West  Indies,  the  pa- 
tients seamen)  was,  to  take  away  fifty,  sixty,  or  seventy  ounces  of  blood  at  the 
first  bleeding;  and  that  his  patients  sometimes  lost  one  hundred  ounces  within 
the  first  twelve  hours,  and  upwards  of  two  hundred  and  fifty  ounces  in  the 
course  of  three  or  four  days  !  I  once  new  a  man  bled  to  eighty-four  ounces  at  one 
bleeding,  in  an  attack  of  fever,  without  suffering  syncope,  or  any  ill  effect 
except  great  disorder  of  the  circulation  for  some  hours  afterwards. 

In  the  following  short  sentence  of  a  celebrated  author,  we  have  at  once  the 
very  best  practice  inculcated,  and  the  very  best  reasons  given  for  its  being 
strenuously  enforced.  Speaking  of  the  treatment  of  pneumonia,  Diermerbroek 
says — "  Vena  igitur  quam  citissime  in  brachio  secandjj,  et  sanguis  liberaliter  ex- 
trahendus  ;  eaque  venresectio,  si  prima  vice  non  imminuitur  morbus,  postea  bis 
terve  reiteranda;  qua  licet  vires  aliquando  dejiciantur,  et  tamen  de  causa  nihil 
metuenduin,  quippe  praestat  aegrum  debilem  sanari,  quam  fortem  mori."  Disput. 
Pract.  de  Morb.  Capitis,  Thoracis,  &c.  p.  56.  The  pithy  remark'in  the  conclu- 
sion of  this  sentence,  coupled  with  the  kindred  one  of  Dr.  Gregory,  ought  to  be 
frequently  suggested  to  the  timid  practitioner. —  Transl. 

*  This  opinion  of  our  author  is  supported  by  almost  all  our  great  authorities, 
and  among  others  by  Stoll,  Cullen,  Frank,  &c.  The  contrary  doctrine,  however, 
has  the  sanction  of  many  most  respectable  names,  as  of  Prirfgle,  &c.  Andral 
joins  with  Laennec  in  stating  that  bleeding  is  positively  beneficial  not  only  in 
the  stage  of  hepatization,  but  even  in  that  of  suppuration.  To  the  testimony  of 
facts  we  can  oppose  no  equivalent  objection;  although,  considering  the  very 
limited  powers  of  art  in  removing  great  alterations  of  structure,  it  might  be 
reasonably  conceived  a  priori,  that  a  hepatized  lung  was  not  likely  to  be  much  un- 
der the  influence  of  venesection.  This  much,  at  least,  I  am  justified  in  stating 
from  my  own  experience,  that  the  vastly  inferior  power  of  bleeding  in  the 
second  and  third  stage  of  pneumonia,  ought  to  make  us  depend  principally  upon 
what  we  can  effect  in  the  first  stage.     And  as  guiding  our  practice  in  thi*  most 


252  TREATMENT  OF  PNEUMONIA. 

The  practice  most  commonly  followed  at  present,  over  the  whole 
of  Europe,  is,  in  the  beginning  of  the  disease,  to  bleed  to  the  ex- 
tent of  from  eight  to  sixteen  ounces,  and  to  repeat  the  operation 
daily,  and  sometimes  even  twice  a  day,  if  the  inflammatory  symp- 
toms do  not  give  way,  or  if,  after  being  subdued  for  a  few  hours, 
they  return  with  fresh  violence.  After  the  first  rive  or  six  days, 
the  bleedings  are  repeated  after  longer  intervals,  and  soon  cease 
altogether,  except  in  cases  where  they  are  strongly  indicated  by 
the  renewed  strength  of  the  pulse,  oppression  and  fever.*  Much 
importance  was  formerly  attached  to  the  particular  vein  to  be 
opened,  the  preference  being  given  to  that  of  the  affected  side. 
At  present  this  is  almost  universally  acknowledged  to  be  a  matter 
of  complete  indifference. 

There  are  some  cases  in  which  bloodletting  is  clearly  contra- 
indicated,  or,  at  least,  in  which  it  can  only  be  used  very  spar- 
ingly, and  once  or  twice  at  most.  Of  this  kind  is  the  pneu- 
monia which  attacks  old  persons  of  a  cachectic  habit,  and  that 
which  supervenes  to  diseases  which  exhibit  obvious  signs  of  a 
septic  state  of  the   fluids,  such  as  the  violent  continued  fevers, 

important  particular,  I  consider  the  stethoscope  as  of  the  utmost  consequence  ;t 
for  without  it  who  shall  say  positively  that  the  disease  is  in  its  first  or  its  sec- 
ond stage  ?  On  this  point  of  practice,  the  opinion  of  Lorinser  is  strongly  against 
bleeding  in  the  latter  stages.  He  says,  that  after  hepatization  has  taken  place, 
bleeding,  by  weakening  the  powers  of  the  system,  impedes  or  altogether  pre- 
vents the  absorption  of  the  effused  lymph ;  and  that  while  one  or  two  venesec- 
tions in  the  first  stage  often  suffice  to  produce  complete  resolution,  six  or  even 
ten  in  the  latter  stage  will  not  only  have  no  good  effect,  but  will  decidedly  has- 
ten the  fatal  event.  He  adds,  that  he  has  repeatedly  proved  the  truth  of  this 
doctrine  in  the  epidemic  pneumonia  of  cattle  (Lungcnscuche  dcr  Rindrr)  in 
which  he  invariably  found  bloodletting  if  not  injurious,  at  least  useless,  after  the 
disease  had  reached  the?  stage  of  hepatization,  (Die  Lehrcvon  den  Lungenkrank- 
heiten,  p.  259. ) — Transl. 

*  It  would  appear  from  the  writings  of  the  modern  Italian  physicians,  that 
bleeding  in  pneumonia  is  carried  to  a  greater  extent  in  Italy  than  our  author 
seems  to  be  aware  of.  Among  others,  see  the  very  sensible  work  entitled  "  Jin- 
notazioni  de  Medicina  Practica  del  dottore  F.  Enrico  Acerb i."  Milano,  1819. 
This  author  states  (Jlnnojirimo,  p.  24.)  that  of  one  hundred  and  forty-two  cases 
of  pneumonia  treated  by  him,  more  than  thirty  were  bled  from  ten  to  twenty 
times,  each  bleeding  being  twelve  ounces ;  and  that  the  usual  practice  was  to 
bleed  night  and  morning,  so  that  in  the  course  of  eight  or  ten  days  from  fifteen 
to  twenty  poands  of  blood  were  taken  away. 

It  is  singular  that  our  author  takes  no  notice  of  the  local  abstraction  of  blood 
by  leeches  or  cupping,  so  important  an  auxiliary  to  the  lancet  in  all  inflammatory 
diseases,  and  so  much  used,  especially  in  his  own  country,  in  this  very  disease. 
It  appears  from  Andral's  work  (t.  ii.  p.  379)  that  M.  Lerminier  is  in  the  habit 
of  using  venesection  and  leeches  simultaneously.  Immediately  after  V.  S.  or 
even  while  the  blood  is  flowing,  "M.L.  fait  souvent  couvrir  de  sangsues  le 
cote  douloureux."  It  is  a  good  general  rule  to  apply  a  large  number  of  leeches 
(from  twenty  to  forty)  to  the  part  most  affected,  an  hour  or  two  after  the  first 
V.  S. ;  to  allow  them  not  to  remain  on  the  body  more  than  a  quarter  of  an  hour 
or  twenty  minutes,  and  when  they  are  removed,  to  envelope  the  whole  side  in  a 
large  soft  warm  poultice.  This  practice  is  still  more  indicated  when  there  exists 
any  pleuritic  complication.  It  need  hardly  be  stated  that  the  local  bleeding 
must  not  supersede  the  use  of  the  V.  S.  if  indicated.—  Transl 


TREATMENT    OF    PNEUMONIA. 


253 


called  putrid  or  adynamic,  and  scurvy.  In  certain  epidemics, 
which  have  occurred  among  persons  previously  subjected  to  the 
influence  of  depressing  causes,  bleeding  has  been  found  uniformly 
injurious.  I  was  myself  witness  of  an  instance  of  this  kind 
among  the  conscripts  of  the  French  army  in  1814.  In  the  pneu- 
monia then  prevalent,  I  very  seldom  found  bloodletting  indi- 
cated, and  the  small  number  who  were  bled  bore  the  operation 
so  ill  that  I  did  not  venture  to  repeat  it.  In  gangrenous  pneu- 
monia, one  bleeding  may  be  useful  at  first,  if  the  patient  is  strong 
and  plethoric  and  the  inflammatory  symptoms  well  marked  ;  but 
we  must  be  careful  not  to  augment  the  septic  tendency  by  carry- 
ing depletion  too  far.  The  same  remark  applies  to  the  remittent 
fevers  denominated  pernicious  peripneumonic.  In  these,  it  may, 
no  doubt  be  sometimes  necessary  to  bleed  during  a  paroxysm,  in 
order  to  prevent  suffocation ;  but  the  utmost  caution  is  requisite 
not  to  destroy  unnecessarily  the  strength  of  the  patient.  We 
must  ever  keep  in  mind,  in  this  case,  that  bloodletting  cannot 
cure  a  disease  which  will  certainly  return  after  a  few  hours  with 
fresh  violence ;  and  of  which  experience  has  long  since  demon- 
strated bark  to  be  the  only  effectual  remedy.*  I  have  had  oc- 
casion to  observe  some  cases  of  pernicious  fever,  existing  under 
the  mask  of  different  inflammatory  affections,  which  were  treated 
by  bleedings  too  frequently  repeated,  and  by  cinchona  given  in 
too  small  doses,  or  left  off  too  soon.  Thes^e  fevers  were  only  im- 
perfectly cured,  and  left  behind  them  various  lesions,  which,  in 
some  cases,  ended  fatally,  and  in  others,  tormented  the  patients 
for  several  years.  .'  The  same  result  was  observed  in  cases  where 
no  blood  was  drawn,  but  in  which  the  bark  was  administered 
in  too  small  quantity,  or  for  too  short  a  time :  an  instance  of  this 
will  be  noticed  in  the  chapter  on  pneumo-thorax.  When  pneu- 
monia is  complicated  with  a  bilious  affection,  bleeding  must,  in 
like  manner,  be  much  more  sparingly  had  recourse  to,  than 
when  the  inflammation  is  simple.  In  all  these  cases,  and  indeed 
in  every  case  whatsoever,  the  more  feeble  the  pulse  is,  the  less 
indication  is  there  for  venesection.  At  the  same  time,  it  is  well 
known  to  every  practitioner  that  this  feebleness  is  sometimes  only 
apparent,  and  that  bleeding  will  render  the  pulse  both  stronger 
and  fuller.     To  discriminate  the  false  from  the  real  feebleness 

*  For  some  excellent  remarks  on  the  relation  which  exists  between  the  fe- 
brile state  (strictly  so  called)  in  intermittent  fevers,  and  the  local  inflammations 
with  which  these  are  so  generally  complicated,  I  beg  leave  to  refer  the  reader  to 
the  valuable  though  too  hypothetical  work  of  M.  Bailly,  entitled  Traite  des 
Fievrcs  intermittentes  simples  it.  pcrnicieuscs.  Paris,  1825.  In  this  work,  the 
result  of  extensive  clinical  and  pathological  observation  among  the  pernicious 
fevers  of  Rome,  the  absolute  necessity  of  administering  the  bark  in  order  to 
check  the  progress  of  the  fever  even  in  cases  complicated  with  the  greatest 
\  isceral  inflammations,  is  clearly  demonstrated.  See  particularly  p.  265,  et  seq 
Sec  also  the  works  of  Morton,  Torti,  Quariii,  ikc.—  TrvfisI 


254  TREATMENT  OF  PNEUMONIA. 

of  pulse,  requires  the  tact  of  an  experienced  practitioner;  and, 
unfortunately,  the  most  expert  in  this  are  often  deceived.  In 
cases  of  this  kind,  the  use  of  the  stethoscope  will  tend  greatly  to 
remove  our  doubts,  as  will  be  seen  when  we  come  to  treat  of  the 
exploration  of  the  heart's  action.  At  present  I  shall  only  ob- 
serve, that  whenever  the  pulsations  of  the  heart  are  (proportion- 
ally) much  stronger  than  those  of  the  arteries,  we  may  bleed 
without  fear,  and  with  the  certainty  of  finding  the  pulse  rise ; 
but  that  if  the  heart  and  pulse  are  both  weak,  the  detraction 
of  blood  will  almost  always  occasion  complete  prostration  of 
strength.*  I  have,  nevertheless,  observed  in  some  cases,  but 
very  rarely,  that  a  small  bleeding,  even  in  such  circumstances, 
has  succeeded  in  restoring  the  energy  of  the  circulation ;  and 
this  has  been  when  the  debility  depended  on  cerebral  conges- 
tion. 

Derivatives. — Most  physicians  consider  blisters  as  being,  after 
venesection,  the  most  efficacious  remedy  in  pneumonia.  Sorrie 
are  accustomed  to  apply  them  to  the  chest  immediately  after  the 
first  bleeding.  Others,  from  an  apprehension  of  increasing  the 
local  congestion,  have  recourse  to  them  only  at  a  later  period,  or 
apply  them  to  the  extremities.  In  my  own  practice,  I  rarely 
apply  blisters  to  the  chest,  particularly  in  the  acute  stage  of 
the  disease,  from  having  very  rarely  observed  any  good  effects 
from  them.  And,  indeed,  it  may  be  stated  as  generally  true, 
that  blisters,  sinapisms,  dry  cupping,  and  other  cutaneous  ex- 
citants, are  of  too  feeble  operation  to  displace  so  energetic  an  irri- 
tation as  that  which  exists  in  acute  pneumonia".  Too  often  they 
increase  the  fever,  and  consequently  the  congestion  in  the  chest. 
And  this  latter  effect  is  still  more  probable  if  they  are  applied  to 
the  thorax ;  in  which  situation  they  are  further  injurious  by  imped- 
ing the  actions  of  the  muscles  of  inspiration.  For  these  various 
reasons,  I  am  of  opinion,  that  the  use  of  blisters  and  other  similar 
applications,  ought  to  be  restricted  to  those-  cases,  in  which  after 
the  acute  stage,  resolution  proceeds  too  slowly,  and  to  the  disease 
in  a  chronic  state ;  and  that  on  all  occasions,  we  should,  if  possi- 
ble, avoid  applying  them  to  the  most  movable  parts  of  the  chest, 
viz.  the  middle  of  the  ribs.f 

I  need  not  point  out  to  the  reader  the  high  practical  importance  of  this 
observation.  I  am  sorry  to  say  that  I  have  only  proved  its  correctness  in  a 
small  number  of  cases,  from  having  failed  to  institute  the  necessary  explorations. 
To  derive  from  the  stethoscope  all  the  benefits  which  it  is  capable  of  affording, 
it  ought  to  be  used  almost  as  frequently  as  the  watch.—  Transl. 

t  Blisters  are  in  general  indicated  in  pneumonia  by  the  exhaustion  of  the 
patient,  the  weakness  of  the  pulse,  and  the  increase  of  dyspnoea  subsequently 
to  the  first  general  blood-letting.  Good  practitioners  neVcr  apply  them,  in  the 
first  instance,  to  the  chest,  but  to  the  legs,  thighs,  or  inside  of  the  arms.  When 
they  fail  to  act  as  derivatives,  blisters  still  operate  beneficially  by  exciting,  tem- 
porarily, the  powers  oY  the  system,  and  thereby  rendering  admissible  further 


TREATMENT    OF    PNEUMONIA. 


255 


Alculis  and  attenuanls  (Fondans.) — The  method  by  which 
the  ancients  proposed  to  themselves  to  render  the  blood  less 
plastic,  consists,  as  we  have  already  stated,  in  the  use  of  alcalis 
more  or  less  neutralized,  particularly  the  subcarbonates  of  potass, 
soda,  or  ammonia  ;  soap  ;  the  neutral  purgative  salts,  such  as  the 
sulphates  of  soda,  potass,  &.c.  given  in  doses  too  small  to  have  a 
cathartic  effect.  To  these  has  been  added,  during  the  last  cen- 
tury, Virginian  snake-root,  from  its  supposed  efficacy  in  curing 
the  bite  of  the  rattle-snake,  which  is  occasionally  found  to  cause 
pneumonia.  This  medicine  has  been  much  used  by  the  Italian 
physicians,  particularly  Sarcone ;  but  both  it  and  the  others 
above  mentioned,  have  appeared  to  me  of  little  use  in  the  treat- 
ment of  pneumonia.  They  favor  expectoration  :  but  their  action 
is  too  slow  and  feeble  to  obtain  for  them  much  of  our  confidence 
as  means  of  arresting  a  disease  so  rapid  in  its  progress.  They 
have  more  effect  when  the  disease  has  assumed  a  chronic  form. 
These  means  are  rarely  used  as  expectorants ;  most  practitioners 
preferring,  with  this  view,  antimonials  or  squills,  and  these  only 
towards  the  termination  of  the  disease :  during  the  acute  stage, 
diluent  and  mucilaginous  drinks  are  employed.* 

I>1< cdings,  particularly  local  bleedings.  Sinapisms  act  in  the  same  manner,  but 
in  a  less  degree.  It  is,  no  doubt,  proper  to  advise  caution  respecting  the  use  of 
these  measures ;  but  I  regard  as  erroneous  the  recommendation  in  the  text,  to 
restrict  their  application  to  cases  of  pneumonia  which  are  slow  in  their  progress 
towards  resolution,  and  yet  more  to  the  chronic  disease,  properly  so  called,  and 
of  which  the  existence  is  always  so  problematical. — (M.  L.) 

An  objection  to  the  use  of  blisters  on  the  chest,  in  the  early  stage  of  pneu- 
monia, not  noticed  by  our  author,  is  their  interfering  in  certain  cases,  with  the 
proper  exploration  of  the  chest  by  percussion  or  auscultation.  I  do  not,  how- 
ever, regard  this  objection  as  of  great  weight ;  as  blisters  should  not  be  applied 
in  the  very  early  stage,  when  it  is  of  most  importance  to  institute  our  physical 
examinations.  When  blisters  are  used  they  should  be  of  large  extent,  as  from 
six  to  eight  or  even  ten  inches  square. —  Transl. 

*  The  alcaline  treatment  of  pneumonia  was  revived  in  Italy  in  the  end  of  last 
century,  with  seemingly  more  philosophical  views  and  in  a  more  active  form, 
by  the  celebrated  Mascagni.  See  his  dissertation  SuW  uso  del-  carbonato  di 
potassa  per  le  renelle  e  peripneumonic.  Mem.  della  Soc.  Ital.  telle  Scienze, 
torn.  xii.  1804.  Partly  from  theoretical  notions  respecting  the  viscidity  of  the 
blood  in  inflammation,  but  chiefly  from  witnessing  the  effect  of  solutions  of  the 
alcalis  in  gravel,  and  in  dissolving  lymphatic  concretions  and  in  softening  por- 
tions of  hepatized  lungs  out  of  the  body,  he  was  led  to  try  and  to  recommend 
their  employment  in  pneumonia.  And  this  practice,  it  is  said,  was  followed 
with  wonderful  benefit  in  an  epidemic  of  this  kind  in  the  year  1800.  The 
practice  of  Mascagni  was  adopted  by  his  pupil,  Dr.  Farnese,  and  by  him  ex- 
tended to  the  treatment  of  phthisis,  and,  according  to  his  testimony,  with  the 
greatest  benefit.  See  Elogio  del  eclchre  anatomico  P.  Mascagni,  di  T.  Farnese. 
Milano,  1816,  p.  84.  86.  108.  etseq.  Dr.  Farnese's  practice  was  to  give  the  car- 
bonate of  potass  to  the  extent  of  from  a  drachm  to  an  ounce,  in  half  a  pint  of 
water  daily.  "Whatever  be  the  severity  of  the  pneumonia  (says  Mascagni), 
whatever  be  its  stage,  this  salt  procures  copious  evacuations  by  the  kidneys,  the 
akin,  the  intestines ;  and,  rendering  the  expectoration  less  viscid  and  more  co- 
pious and  fluid,  speedily  resolves  the  inflammatory  infarctus  of  the  pulmonary 
tissue." — The  unquestionable  effects  of  alcaline  remedies  in  relieving  and  cur- 
ing calculous  complaints,  as  proved  by  Mrs.  Stephen's  medicine,  and   by  the 


256  TREATMENT  OF  PNEUMONIA. 

Purgatives  and  emetics. — It  is  in  general  advisable  to  keep 
the  bowels  open  in  pneumonia,  especially  on  the  approach  of 
convalescence  ;  and  this  object  is  commonly  attained,  with  suffi- 
cient effect  by  means  of  glysters  and  gentle  laxatives.  Purga- 
tives under  the  name  of  derivatives,  are  employed  by  some  prac- 
titioners, with  the  view  of  lessening  the  congestion  within  the 
chest.*  Emetics  have  also  been  much  used,  either  as  derivatives 
or  from  the  inflammation  being  complicated  with  bilious  disorder. 
Stoll  employed  them  constantly,  in  conjunction  with  bloodletting, 
in  the  beginning  of  the  disease ;  and  the  same  practice  was  fol- 
lowed by  Corvisart.  Finke,  in  the  Tecklembourg  epidemic,  fre- 
quently cured  pneumonia  (which  he  looked  upon  as  only  a  con- 
cealed form  of  bilious  disease)  by  emetics  alone.  At  present 
this  mode  of  practice  is  very  rarelv  had  recourse  to,  bilious  af- 
fections being  now  uncommon  and  of  little  severity. 

Tonics.- — These,  and  especially  bark,  are  often  very  useful  in 
the  pneumonias  of  old  persons  and  debilitated  and  cachectic 
subjects,  especially  towards  the  termination  of  the  disease,  when, 
after  the  suppurative  stage,  the  fever  passes  off  and  resolution 
goes  on  very  slowly.  In  the  same  circumstances  the  ancients 
recommended  wine,f  a  practice  which  I  have  myself  sometimes 
followed  with  success.  We  sometimes  even  meet  with  epidemic 
pneumonias  in  which  bloodletting  is  constantly  hurtful,  and  the 
bark  beneficial  in  every  stage  of  the  disease.  This  fact,  which 
cannot  be  denied,  was  frequently  witnessed,  particularly  in  Ger- 
many, towards  the  close  of  the  last  century ;%  and  there  is  no 
doubt,  that  Brown's  theory  was  indebted  to  this  medical  consti- 

more  recent  and  scientific  experience  of  Brande,  Magcndie,  &c.  give  consider- 
able countenance  to  the  plan  of  treating  pneumonia  recommended  by  Mascagni, 
and  fully  justify  more  ample  trials  of  it.  Speaking  of  the  treatment  id'  this 
disease, Dr.  Darwin  (Zoon.  vol.  ii.  p.  314)  asks — whether  neutral  salts  may  nut 
augment  cough  by  their  stimulus,  as  they  increase  the  beat  of  urine  in  gonor- 
rhoea? It  may  be  said  of  Darwin's  queries,  as  of  Newton's,  that  they  are  often 
better  than  other  people's  assertions;  and  I  think  the  above  is  one  well  de- 
serving our  attention,  but  more  so,  perhaps,  in  bronchitis  than  in  simple  pneu 
monia. —  Thransl. 

*  There  has  been  much  difference  of  opinion  among  authors  on  the  eligibility 
of  purgation  in  pneumonia.  I  believe  that  the  use  of  gentle  laxatives  recom- 
mended-in  the  text,  is  all  that  is  admissible.  The  common  practice  of  this 
country  at  present,  is  too  much  disposed  towards  purgation  in  all  diseases  In 
pneumonia  this  practice  is  attended  by  many  disadvantages;  while  the  benefi- 
cial effects  expected  from  it,  whether  derivative  or  simply  depletory,  can,  I 
conceive,  be  obtained  much  more  certainly  by  other  and  safer  measures.  In 
the  not  unusual  complication  of  pneumonia  with  gastric  inflammation  or  irrita 
tion,  purgatives  are  very  improper,  and.  I  believe,  do  much  mischief  in  the 
hands  of  routine  practitioners  in  this  country. — Transl 

t  Aret.  de  Curat,  Aeut.  lib.  ii.  cap.  I 

|  Bang.  Act.  Reg.  Soc.  Med.  Hafn.  v.  i.  p.  25G ;  ./-/,/,/„/    .Mem  de  la  S j 

de  Med.  1/76,  p.  87;   Frank,  Erlauterungen  der  Brownischen  arzeneylehi    vi 
abschnit.  i.;  Horn,  Bcytragc  Zur  Med.   Kim   i    p  27<j  517.   Gcbcl,  Hufeland- 
Journ.  xvu.  B.  p.  51 ,  Rademacher ,  ibid.  xvi  B  p.  103. 


TREATMENT    OF    PNEUMONIA. 


257 


tution  for  a  portion  of  the  fame  it  obtained  in  that  country. 
Numerous  examples  of  the  same  kind  are  recorded  in  the  old 
Journal  de  Medecine ;  and  I  have  myself  met  with  many,  par- 
ticularly in  the  epidemic  among  the  troops  in  1814,  already  men- 
tioned. In  gangrene  of  the  lungs,  cinchona  is  the  best  remedy. 
I  have  used  it  successfully,  even  in  cases  where  the  hepatization 
around  the  eschar  was  very  extensive ;  and  have  sometimes  even 
combined  wine  and  opium  with  it,  when  the  violence  of  the  in- 
flammatory symptoms  had  begun  to  subside.  To  be  effectual 
it  must  be  given  to  the  extent  of  an  ounce  of  the  powder,  or  an 
equivalent  portion  of  the  extract,  daily.  In  several  cases  I  have 
continued  to  give  the  sulphate  of  quinine  for  more  than  a  month, 
to  the  extent  of  eighteen  grains  in  the  twenty-four  hours.  Opium 
by  itself  has  never,  as  far  as  I  know,  been  recommended  as  a  re- 
medy in  pneumonia.  We  even  know  that  it  is  capable,  in  large 
doses,  of  producing  the  disease — instances  of  which  I  have  my- 
self seen  subsequent  to  cases  of  poisoning.  It  has,  however,  been 
sometimes  .  employed  with  success  in  the  same  circumstances  as 
the  bark.  With  these  exceptions,  it  should  only  be  used,  and 
then  cautiously,  to  quiet  nervous  irritation,  to  procure  sleep,  or 
to  check  an  excessive  diarrhoea. 

Alteratives. — The  ancients  gave  the  name  of  alteratives  to  such 
medicines,  as,  without  occasioning  any  constant  or  marked  evac- 
uation, effected  the  resolution  of  different  kinds  of  obstruction, 
particularly  those  of  an  inflammatory  character.  Almost  all 
these  agents  we  now  regard  as  stimulants  of  the  lymphatic  sys- 
tem, and  in  this  way  explain  their  resolvent  action  :  of  this  kind 
are  the  alcalis,  neutral  salts,  purgatives,  and  even  expectorants, 
such  as  squills,  and  especially  antimony.  On  the  same  principle, 
mercury  has  of  late  years  been  much  employed,  particularly  in 
England  and  Germany,  although  perhaps  the  practice  was  still 
earlier  used  in  Italy  by  Sarcone.  Calomel  and  the  soluble  mer- 
cury of  Hahnemann,  are  the  preparations  most  used,  and  with 
these  preparations  some  physicians  may  have  combined  opium, 
to  prevent  their  action  on  the  bowels.  I  have  not  myself  had 
sufficient  experience  of  this  method  [in  pneumonia]  to  be  able  to 
appreciate  its  merits :  but  I  have  employed  it  enough  in  other 
inflammatory  affections,  particularly  peritonitis,  to  be  able  to 
state,  that  it  is  not  of  great  power  except  when  carried  to  the 
extent  of  determining  an  incipient  ptyalism,  with  fvjiiclr  the  first 
marks  of  resolution  show  themselves.  In  peritonitis,  the  in- 
flammatory orgasm  decreases  as  soon  as  the  gums  begin  to  be 
swollen.* 

*  Both  opium  and  calomel,  separately  or  conjoined,  have  been  extensively  em- 
ploj  ed  in  England,  in  the  cure  of  pneumonia  and  other  acute  inflammations  ;  and 
with  a  degree  of  success  which  entitles  them  to  the  greatest  confidence  of  prac- 

33 


258  TBEATMEN1  OF  PNEUMONIA 

TJie    means    above    detailed,  variously    combined,    constitute 
nearly  all  the  curative  resources  employed  by  the  greater  num- 

titioners,  as,  at  least,  powerful  auxiliaries  of  our  best  antiphlogistic  measures. 
The  practice  was  first  introduced  to  the  notice  of  the   profession  by  Dr.  Robert 
Hamilton  of  Lynn  Regis,  in  a  paper  printed  in  ihe  9th  vol.  of  the  Medical  Com- 
mentaries.    In  this  paper,  which  was  first  published  in  the  year  1785,  the  author 
states  that  he  had  been  in  the  habit  of  employing  calomel  and  opium  in  the  cure 
of  inflammatory  diseases  for  nearly  twenty  years.     His  practice  was,  after  bleed- 
ing and  opening  the  boioels,  to  give  "  a  composition  consisting  of  from  five  to  one 
grain  of  calomel,  and  from  one  to  one-forth  grain  of  opium,  every  six,  eight,  or 
twelve  hours,  as  the  degree  of  inflammation,  or  the  threatening  aspect  of  the 
distemper  seemed  to  require;  and  a  plentiful  dilution  with  barley  water,  or  any 
other  weak  tepid  beverage,  was  at  the  same  time  strictly  enjoined."     P.  199. 
He  says  that  after  the  resolution  was  taken  to  make  trial  of  this  mode  of  treat- 
ment, pneumonia  was  the  first  disease  that  fell  under  his  care,  and  adds — that 
the  success  attending  the  administration  of  calomel  and  opium  in  this  disease 
was  "such  as  to  fill  him  with  astonishment."  P.  196.     This  practice  has  been 
adopted  and  recommended  by  many  subsequent  writers  :  and  I  presume  there  are 
few  practitioners  in  this  country  who  have  not  experienced  its  great  power  in 
their  own  hands.     Dr.  Armstrong,  while  expressing  his  opinion  that  Dr.  Hamil- 
ton's plan  is  defective,  inasmuch  as  the  precursory  depletion  is  too  slight,  and  the 
doses  of  calomel  too  small  or  too  seldom  repeated,  says   that  it  "deserves  to  be 
written  in  letters  of  gold,  on  account  of  its  great  practical  utility."     On  Typhus, 
2nd  Ed.  p.  144.     To  the  author  just  named  we  are  indebted  not  merely  for  re- 
calling the   attention  of  practitioners  to  this  practice,  in  the  work  just  quoted, 
but  for  an  important  modification  of  it  in  the  early  stage  of  inflammatory  disea- 
ses.    See  a  paper  On  the  Utility  of  Opium  in  certain  Inflammatory  Disorders,  in 
the  Trans,  of  the  Apothecaries,  vol.  i.     In  this  paper,   although  the   author  re- 
commends calomel  to  be  conjoined  with  the  opium,  after  the  first  dose,  it  is  evi- 
dent that  he  considers  the  great  benefit  of  the  practice  as  flowing  from  the  opium 
alone.     This  he  gives  immediately  after  bleeding  to  stjncopc  or  approaching  syn- 
cope, in  a  dose  of  at  least  three  grains.      Dr.  Armstrong  expresses  himself  in  the 
strongest  terms  of  commendation  of  this  method  :  and  I  am  happy  to   add  my 
own  testimony  to  the  same  effect,  in  the  cases  where  I  have  had  occasion  to  use 
it.     To  such  as  have  not  seen  the  papers  of  Drs.  Hamilton  and  Armstrong  above 
mentioned,  I  strongly  recommend  the  perusal  of  them.    The  following  observa- 
tions by  Dr.  Williams  on  this  plan  of  treatment  are   extremely  judicious,   and 
merit  the  attention  of  the  young  practitioner  : — "  The  efficacy  of  this  combination 
depends  in  a  great  measure  on  its  being  given  to  such  an   extent  as  to  affect  the 
gums ;  but  its  beneficial  operation  is  often  manifest  before  this  effect  is  produced, 
and  in  some  cases,  especially  in  children,  without  its  occurring  at  all.     But  there 
is  seldom  that  obvious  improvement  from  the  first  doses  which  is  often  appa- 
rent in  the  exhibition  of  tartar-emetic  ;  the  operation  of  mercury  is  more  gradual, 
and,  as  may  be    expected,  when  once  the    system   is   under  its  influence,  the 
effect  is  more   permanent.      It  is  therefore   especially  adapted  to   the  advanced 
stages  of  the  disease,  in  which  the  continued  operation  of  a  remedy  is  required 
to  resolve  a  solidification  of  the  lung  ;  and  in  effecting  this,  and  in  preventing 
those  remains  of  inflammation  which  lay  the  foundation  for  destructive  chronic 
disease,    mercury    is    pre-eminently    serviceable.       Some    doubt    has    existed 
whether  the  mercury  or  the  opium  is  the  principal  agent  in  subduing  inflamma- 
tion.    Dr.   Hamilton  considered  it  to  be   the  calomel,  and  he   combined  opium 
with  it  to  relieve-pain,  and  to  prevent  it  from  passing  off"  by  the  bowels.     Dr. 
Armstrong  held  that  the  opium  was  a  powerful  means  of  subduing  inflammation 
after  bleeding  had  made  a  decided  impression  on  the  general  vascular  action.     In 
pneumonic  inflammation,  however,  we  cannot  but  admit  that  both  medicines 
have  their  beneficial  effects,  each  by  its  own  influence,  and  by  modifying  the 
action  of  the  other.     Thus  the  opium  acts  as  an  anodyne  in  subduing  the  pain 
and  cough,  and  as  a  sedative  in  relieving  that  nervous  irritation  which  often  fol- 
lows both  bleeding  and  the  free  use  of  mercury,  and  which  tends  to  the  re-estab- 
lishment of  inflammation  ;  whilst  the  injurious  stimulant  and  restringent  opera- 
tion of  the  drug  is  prevented  by  the  previous  bloodletting  and  the  mercury.    The 


TREATMENT  OF  PNEUMONIA. 


259 


ber  of  European  physicians.  Judging  from  the  necrological 
tables  published  of  late  years,  and  from  the  information  I  have 
obtained  from  the  practitioners  of  different  countries,  I  would 
state  the  common  result  of  this  method  to  be,  a  mortality  of  one 
in  eight  at  least,  and  one  in  six  at  most. 

Tartar  emetic  in  large  doses. — The  preparations  of  antimony 
have  been  employed  in  large  closes,  either  empirically  or  on 
theoretical  grounds,  as  a  means  of  cure  in  different  inflammatory 
diseases.  During  the  seventeenth  century,  more  especially,  to 
judge  from  the  remaining  memorials  of  the  controversies  of 
those  days,  some  brilliant  cures  and  many  unfortunate  events 
were  the  consequence  of  this  practice.  These  latter  results  may 
perhaps  be  attributable  partly  to  the  preparations  being  too 
active,  and  partly  to  ignorance  of  the  proper  method  of  using 
them.  Be  this  as  it  may,  we  meet  with  traces  of  this  practice, 
from  time  to  time,  in  the  writings  of  the  physicians  of  the  last 
century.  1  do  not  here  allude  to  the  exhibition  of  the  medicine 
in  small  doses  as  an  emetic,  nor  to  the  method  of  Riverius,  who 
vomited  his  pneumonic  patients  with  it  daily,  or  every  second  day  ; 
but  may  remark,  in  passing,  that*  this  practice  has  always  had 
partisans  among  practitioners.  Every  one  knows  the  anecdote  of 
the  elder  Serane  quoted  by  Borden*  It  was  constantly  followed, 
to  my  own  knowledge,  by  M.  Dumangin,  Physician  to  La  Charite, 
in  pneumonia.  This  gentleman  scarcely  ever  combined  blood- 
letting with  it,  and  yet  his  practice  was  quite  as  successful  as  that 
of  Corvisart,  who  bled  much  in  this  disease.  But  administered 
in  this  way,  the  remedy  is  an  evacuant,  and  its  good  effects  may 
consequently  be  attributed  to  the  derivation  operated  by  it  on  the 
intestinal  canal. 

The  employment  of  kermes  mineral  as  an  expectorant  may 
be  considered  as  a  relic  of  its  ancient  use  as  an  alterant.  In 
the  old  Formulaire  des  Hopitaux  de  Paris,  printed  in  1764, 
we  find  the  remains  of  a  still  bolder  practice,  in  a  potion 
entitled  in  pleuritide  et  in  peripneumonia,  and  which  consists  of 
four  drachms  of  the  white  oxyd  of  antimony  in  four  ounces  of 
the  infusion  of  borrage.     The  famous  bolus  ad  quartanam  of 

latter  medicine  again,  besides  this  corrigent  effect,  more  gradually  exerts  thai 
specific  antiphlogistic  and  sorbefacient  action  which  has  established  its  value  in 
many  diseases,  and  of  which  the  treatment  of  iritis  frequently  affords  a  visible 
illustration.  If  we  adopt  this  view  as  a  guide  in  the  application  and  manage 
meal  of  these  combinations,  we  shall  find  that  it  leads  to  the  rules  which  eispe 
rience  has  already  sanctioned."   (Cyc.  of  Prae.  Med.  vol.  iii.  p.  442.)—  Trans/. 

'  Traitc  flu .Ti~s.su  mill/ iir in 5,  Par.  1767, p  22l.  Serane  followed  the  method 
of  Riverius,  and  very  successfully,  in  treating  fluxions  on  the  chest.  His  son, 
however,  fresh  from' the  schools,  succeeded  in  persuading  him  that  he  bled  too 
sparingly  and  gave  emetics  too  freely.  This  produced  asingular  indecision  and 
in»  tivitj  of  practice  which  made  him  now  and  then  exclaim,  when  he  wished 
to  give  an  emetic,  but  did  not — Monfil,  m'abes  gastai!  My  son  you  hav< 
spoil!  me  !"  —  Jluthoi 


260  TREATMENT  OF  PNEUMONIA. 

La  Charite,  is  another  proof  of  the  employment  of  antimony  in 
large  doses,  and  as  an  alterant.  I  have  been  informed  that  the 
practice  of  giving  antimony  to  this  extent,  was  longer  preserved 
in  Italy  than  in  any  other  countries  of  Europe.  At  all  events, 
it  is  to  a  modern  Italian  physician,  Rasori,  that  we  are  indebted 
for  the  revival  and  demonstration  of  the  utility  of  this  method, 
which  had  fallen  too  much  into  disuse.  I  say  nothing  here  of 
this  author's  theory,  or  rather  of  his  modification  of  the  theory  of 
Brown.  The  doctrine  of  stimulus  and  contra-stimulus  has 
hitherto  found  partisans  only  in  Italy,  and  will  perhaps  never 
reach  beyond  the  alps ;  but  practical  facts  of  such  importance 
as  those  in  question,  ought  to  find  all  medical  men,  whatever  be 
their  theoretical  opinions,  disposed  to  put  them  to  the  test  of  ex- 
periment. I  am  unacquainted  with  the  details  of  Rasori's  prac- 
tice, the  first  idea  of  whose  method  I  derived  from  some  medical 
men  who  had  been  in  Italy.  I  began  to  make  trial  of  it  in  1817, 
and  learned  at  the  same  time  that  my  colleague,  M.  Kapeler, 
had  tried  it  with  some  benefit,  and  without  any  inconvenience, 
in  cases  of  apoplexy.  For  a  long  time  I  restricted,  with  him, 
my  trials  to  this  disease ;  but  having  occasion  to  attend  two 
cases  of  pneumonia,  in  which  venesection  was  not  practicable,  I 
resolved  to  make  use  of  the  tartar  emetic  in  large  doses :  and 
the  recovery  of  both  patients,  equally  rapid  as  unexpected,  en- 
couraged me  to  repeat  its  employment  in  many  other  cases.* 

I  shall  here  detail  the  manner  in  which  I  administer  this  re- 
medy, and  which  differs,  I  believe,  in  some  respects  from  that  of 
Rasori.  As  soon  as  I  recognize  the  existence  of  the  pneumonia, 
if  the  patient  is  in  a  state  to  bear  venesection,  I  direct  from  eight 
to  sixteen  ounces  of  blood  to  be  taken  from  the  arm.  I  very 
rarely  repeat  the  bleeding,  except  in  the  case  of  patients  affected 
with  disease  of  the  heart,  or  threatened  with  apoplexy,  or  some 
other  internal  congestion.  More  than  once  I  have  even  effected 
very  rapid  cures  of  intense  pneumonias  without  bleeding  at  all ; 
but,  in  common,  I  do  not  think  it  right  to  deprive  myself  of  a 
means  so  powerful  as  venesection,  except  in  cachectic  or  debili- 
tated subjects.  In  this  respect  Rasori  does  the  same.  I  regard 
bloodletting  as  a  means  of  allaying,  temporarily  at  least,  the  vio- 
lence of  the  inflammatory  action,  and  giving  time  for  the  emetic 
tartar  to  act.     Immediately  after  bleeding  I  give  one  grain  of 

*  It  was  in  1821  that  Lacnnec  began  to  employ  the  tartar  emetic  in  large  doses, 
in  pneumonia  and  some  other  inflammatory  diseases  ;  and  at  this  period  he  might 
truly  say  that  he  was  unacquainted  with  the  details  of  Rasori's  practice,  as  it 
was  then  very  little  known  in  France.  In  1825,  however,  when  he  printed  his 
second  edition,  he  was  not  ignorantof  it,  M.  Fontaneilles  having  given  an  account 
of  it,  twelve  months  before,  (Archives  Gen  de  Med.  Fev.  et.  Mars,  1824,)  in  his 
Translation  of  Rasori's  Memoir  on  pneumonia  and  the  mode  of  treating  it  '"/ 
Emetic  Tartar— {M.  L.) 


TREATMENT    OF    PNEUMONIA.  ^°1 

the  tartar  emetic,  dissolved  in  two  ounces  and  a  half  of  cold  weak 
infusion  of  orange-leaf,  sweetened  with  half  an  ounce  of  syrup  of 
marsh-mallows  or  orange-flowers  ;  and  this  I  repeat  every  second 
hour  for  six  times;  after  which  I  leave  the  patient  quiet  for 
seven  or  eight  hours,  if  the  symptoms  are  not  urgent,  or  if  he 
experiences  any   inclination  to  sleep.     But  if  the  pneumonia  has 
already  made  progress,  or  if  the  oppression  is  great,  or   the  head 
affected,  or  if  both   lungs  or  one  whole  lung  is  attacked,  I  con- 
tinue the  medicine  uninterruptedly,  in  the  same   dose  and  after 
the  same    intervals,  until  there  is   an    amendment,  not  only  in 
the    symptoms   but  indicated   also    by   the   stethoscopic    signs. 
Sometimes  even,  particularly  when  most  of  the  above-mentioned 
unfavorable   symptoms   are    combined,  I    increase  the    dose    of 
the  tartar  emetic  to   a  grain  and  a   half,  two  grains,  or    even 
two  grains  and  a   half,  without  increasing   the  quantity  of  the 
vehicle.     Many  patients  bear  the  medicine  without  being  either 
vomited  or  purged.      Others,  and  indeed    the  greater  number, 
vomit  twice  or  thrice  and  have  five  or  six  stools  the  first  day ; 
on  the  following  days   they  have  only  slight  evacuations,   and 
often  indeed  have  none  at  all.     When  once  tolerance  of  the  me- 
dicine (to  use  the  expression  of  Rasori)  is  established,   it  even 
very  frequently  happens  that  the  patients  are  so  much  consti- 
pated as  to   require  clysters  to  open  the  body.     When  the  evac- 
uations  are   continued    to    the  second  day,  or   when    there   is 
reason  to   fear   on   the  first,  that   the  medicine  will  be  borne 
with  difficulty,  I  add  to  the  six  doses,  to   be  taken   in  twenty- 
four  hours,  one  or  two  ounces  of  the  syrup  of  poppies.     This 
combination  is  in   opposition  to  the  theoretical  notions  of  Rasori 
and  Tommasini,  but  has  been  proved  to  me  by  experience  to  be 
very  useful.     In  general  the  effect  of  tartar  emetic  is  never  more 
rapid  or  more  efficient  than  when  it  gives  rise  to  no  evacuation  ; 
sometimes,  however,  its  salutary  operation  is   accompanied  by  a 
general  perspiration.     Although  copious    purging  and    frequent 
vomiting  are  by  no  means  desirable,  on  account  of  the  debility 
and  the  hurtful  irritation  of  the  intestinal  canal  which  they  may 
occasion,  I  have  obtained  remarkable  cures  in  cases  in  which 
such  evacuations  had  been  very  copious.     I  have  met  with  very 
few  cases  of  pneumonia  where  the  patient  could  not  bear  the 
emetic  tartar  ;  and  the  few  I  have  met   with  occurred  in  my 
earliest  trials  ;  insomuch  that  this  result  now  appears  to  me  to  be 
attributable  rather  to  the  inexperience  and  want  of  confidence 
of  the   physician,  than  to  the  practice.     I  now  frequently  find 
that  a   patient  who  bears  only  moderately  six  grains  with  the 
syrup  of  poppies,  will  bear  nine  perfectly  well  on  the  following 
day.     At   the  end  of  twenty-four  or  forty-eight  hours  at  most, 
frequently  even  after  two  or  three  hours,  we  perceive  a  marked 


262  TREATMENT  OF  PNEUMONIA 

improvement  in  all  the  symptoms.  And  sometimes  even,  we  find 
patients,  who  seemed  doomed  to  certain  death,  out  of  all  dangei 
after  the  lapse  of  a  few  hours  only,  without  having  ever  experi- 
enced any  crisis,  any  evacuation,  or  indeed  any  other  obvious 
change  but  the  rapid  and  progressive  amelioration  of  all  the 
symptoms.  In  such  cases  the  stethoscope  at  once  accounts 
for  the  sudden  improvement,  by  exhibiting  to  us  all  the  signs 
of  the  resolution  of  the  inflammation.  These  striking  results 
may  be  obtained  at  any  stage  of  the  disease,  even  after  a 
great  portion  of  the  lung  has  undergone  the  purulent  infiltration. 
As  soon  as  we  have  obtained  some  amelioration,  although  but 
slight,  we  may  be  assured  that  the  continuation  of  the  remedy 
will  effect  complete  resolution  of  the  disease,  without  any  fresh 
relapse  ;  and  it  is  in  regard  to  this  point  more  particularly  that 
the  greatest  practical  difference  between  the  emetic  tartar  and 
bloodletting  consists.  By  the  latter  measure,  we  almost  always 
obtain  a  diminution  of  the  fever,  of  the  oppression  and  the  bloody 
expectoration,  so  as  to  lead  both  the  patient  and  the  attendants 
to  believe  that  recovery  is  about  to  take  place :  after  a  few  hours, 
however,  the  unfavorable  symptoms  return  with  fresh  vigor ;  and 
the  same  scene  is  renewed,  often  five  or  six  times,  after  as  many 
successive  venesections.  On  the  other  hand,  I  can  state  that  I 
have  never  witnessed  these  renewed  attacks  under  the  use  of  the 
tartar  emetic.  In  these  cases  we  observe  only,  in  the  progress 
towards  convalescence,  occasional  stoppages.  And  this  is  more 
particularly  the  case  in  respect  of  the  stethoscopic  signs  ;  as  we 
find  that,  between  the  period  when  the  patient  experiences  a  re- 
turn of  his  appetite  and  strength,  and  fancies  himself  quite  cured, 
and  the  period  at  which  the  stethoscope  ceases  to  give  any  indi- 
cation of  pulmonary  engorgement, — more  time  frequently  elapses 
than  between  the  invasion  of  the  disease  and  the  beginning  of 
the  convalescence.  It  is  necessary  to  observe,  however,  that  this 
remark  is  still  more  frequently  applicable  to  the  disease  when 
treated  by  bloodletting  ;  and  moreover,  that  the  patients  sub- 
jected to  the  antimonial  method  never  experience  the  long  and 
excessive  debility  which  too  often  accompanies  the  convalescence 
of  those  who  had  been  treated  by  repeated  venesections. 

The  best  way  of  appreciating  any  particular  mode  of  treat- 
ment is  by  its  results.  I  am  sorry  to  say  that  I  only  began  last 
year  [1824]  to  keep  an  exact  account  of  the  results  of  mine  by 
the  tartar  emetic  ;  but  I  can  affirm  that  I  have  no  recollection  of 
death  from  acute  pneumonia  in  any  case  where  this  medicine 
had  been  taken  long  enough  for  its  effects  to  be  experienced. 
1  ha*ve  only  witnessed  a  few  fatal  terminations  where  the  case 
was  a  slight  pneumonia  complicated  with  severe  pleurisy.  (We 
shall  find,  when  we  come  to  treat  of  the  latter  disease,  that  after 


TREATMENT  OF  PNEUMONIA. 


263 


the  first  stage,  the  emetic  tartar  has  little  effect  in  it.)  I  have 
also  lost  some  patients  who,  besides  the  pneumonia,  were  affected 
with  cancer,  phthisis,  disease  of  the  heart,  he. ;  and  these  are 
the  cases  where  I  had  an  opportunity  of  observing  the  different 
degrees  of  resolution  in  this  disease.  Finally,  I  have  lost  some 
who  were  brought  to  the  hospital  moribund,  and  who  sunk  before- 
they  had  taken  more  than  two  or  three  grains  of  the  remedy. 

In  the  year  1824,  at  the  Clinic  of  the  Faculty  of  Medicine,  I 
treated  by  the  tartar  emetic  twenty-eight  cases  of  pneumonia, 
either  simple  or  complicated  with  slight  pleuritic  effusion.  Most 
of  these  cases  were  very  severe,  yet  they  were  all  cured,  with  the 
single  exception  of  a  cachectic  old  man  of  seventy,  who  took  but 
little  of  the  medicine  because  he  bore  it  badly.  During  the 
present  year,  [1825]  I  have  treated  thirty-four  cases  in  the  same 
manner.  Of  these,  five  have  died  ;  but  of  this  number  two 
women,  one  aged  fifty-nine  and  the  other  sixty-nine,  were 
brought  to  the  hospital  moribund,  and  sunk  before  they  had 
taken  more  than  two  or  three  doses  of  the  emetic  tartar  ;  a  third 
died  of  disease  of  the  heart  when  convalescent  from  the  pneu- 
monia ;  and  a  fourth  fell  a  victim  to  chronic  pleurisy,  also  in  the 
period  of  resolution  of  a  sub-acute  pneumonia.  These  two  last 
cases  will  be  detailed  hereafter  ;  the  one  at  the  end  of  the  pre- 
sent chapter,  the  other  in  the  section  on  pleuro-pneumonia.  The 
fifth  case  was  that  of  a  man,  seventy-two  years  of  age,  who  died 
of  cerebral  congestion  on  the  tenth  day  of  the  disease.  Of  these 
five  cases,  then,  the  two  first  cannot  be  adduced  in  either  way  as 
instances  of  the  effect  of  this  remedy  ;  and  the  two  next  afford 
proofs  of  its  efficacy  in  pneumonia,  rather  than  the  contrary. 
The  result,  therefore,  of  the  whole  is,  that  of  fifty-seven  cases  of 
pneumonia  treated  by  the  tartar  emetic,  only  two  individuals, 
both  upwards  of  seventy,  died  of  this  disease  conjoined  with 
cerebral  congestion, — that  is,  a  little  less  than  one  in  twenty- 
eight.*  In  private  practice,  during  the  last  three  or  four  years,  I 
have  not  been  called,  in  consultation,  to  cases  of  acute  pneumo- 

*  In  this  calculation  Laennec  has  included  all  the  cases  of  pneumonia  re- 
ceived into  the  Clinic,  without  distinction  as  to  the  severity  or  mildness.  Such 
a  distinction,  however,  is  necessary  to  enable  us  to  appreciate  accurately  the 
effect  of  the  treatment  on  the  mortality.  It  cannot  be  proper  to  take  into  ac- 
count, in  such  comparative  statements,  cases  so  slight  that  abstinence  from  food, 
confinement  to  bed,  a  few  leeches,  or  a  very  trifling  venesection,  sufficed  to 
cure  :  and  yet  I  know  that  of  the  fifty-seven  cases  of  pneumonia  cited  in  the 
text,  the  fourth  part  at  least,  more  especially  of  the  thirty-four  treated  in  1825, 
were  of  this  kind.  In  reckoning  only  the  cases  of  well-marked  pneumonia 
and  in  which  there  was  time  for  the  remedy  to  take  effect,  the  mortality,  ac- 
cording to  my  notes,  ought  to  be  reckoned  as  one  in  twenty  or  even  eighteen. 
It  is  probable  that  a  similar  correction  may  apply  to  the  results  of  treatment  re- 
corded by  M.  Benaben  who  informs  us,  in  a  very  interesting  memoir  recently 
published  in  the  Rente.  Medicate,  (Oct.  and  Dec.  1829.)  that  he  only  lost  one 
patient  in  forty-five— (M.  L.) 


264  TREATMENT  OF  PNEUMONIA. 

nia,  or  to  cases  uncomplicated  with  violent  pleurisy,  except  such 
as  appeared  already  threatening  a  fatal  termination ;  and  I  yet 
do  not  remember  a  single  case  which  proved  fatal  under  the  use 
of  the  emetic  tartar,  except  that  of  a  plethoric  subject,  aged 
seventy-two,  whom  I  attended  along  with  Dr.  Juglar.  This  pa- 
•tient  labored  under  a  relapse  of  pneumonia  after  a  delusive  con- 
valescence, the  third  attack  of  the  kind  he  had  had  during  the 
preceding  fifteen  months.  The  fever  was  intense,  with  sub- 
delirium  and  other  signs  of  cerebral  congestion.  He  took  the 
emetic  tartar  to  the  amount  of  six  grains  daily  for  two  days : 
tolerance  was  established  on  the  second  day ;  the  pneumonic 
symptoms  decreased ;  the  expectoration  became  again  mucous ; 
but  he  sunk  on  the  third  day  from  an  increase  of  the  cerebral 
congestion.  To  this  case  I  can  oppose  two  others  where  the 
probabilities  of  success  were  less,  and  where,  nevertheless,  a 
rapid  recovery  took  place. 

A.  man  aged  forty-five,  weakened  by  various  excesses,  was 
seized  with  pneumonia  in  1823.  I  saw  him  on  the  fourth  day  in 
a  state  almost  hopeless.  The  right  lung  was  affected  throughout, 
notwithstanding  venesection  had  been  repeatedly  used.  There 
was  extreme  oppression  of  the  chest ;  and,  during  the  last  twelve 
hours,  jaundice,  with  pain  in  the  region  of  the  liver,  had  come 
on,  indicating  the  supervention  of  hepatitis.  I  recommended  the 
tartar  emetic,  which  the  attendant,  Dr.  Mitchel,  the  more  readily 
agreed  to,  from  having  seen  it  used  by  Rasori  at  Milan.  We 
prescribed  twenty  grains  to  be  taken  during  the  twenty-four 
hours,  in  two-grain  doses ;  but  by  mistake  about  forty  grains 
were  given,  within  the  same  period.  This  treatment  occasioned 
but  little  evacuation,  and  on  the  following  day,  we  found  the 
jaundice,  the  pain,  and  the  oppression  gone,  the  stethoscopic 
signs  perceptibly  improved,  the  fever  less,  and  the  patient,  in 
short,  out  of  danger.  Convalescence  proceeded  without  any 
relapse. 

In  June  1825,  I  was  called  to  M.  de  C — ,  aged  65,  by  M. 
M.  Landre-Beauvais  and  Jadioux.  I  found  the  patient  in  the 
eleventh  day  of  pneumonia.  He  had  been  repeatedly  bled  with 
marked  relief,  but  this  was  always  speedily  followed  by  a  re- 
newal of  the  violence  of  the  disease.  Since  the  preceding  day, 
he  had  been  insensible,  and  he  now  lay  with  the  trachial  rhon- 
chus  of  the  dying,  and  covered  with  a  sweat,  which  felt  cold  on 
the  extremities.  Two  days  before,  the  dibility  not  justifying  the 
loss  of  more  blood,  tartar  emetic  had  been  tried ;  but  the  first 
doses  having  increased  a  diarrhoea  which  the  patient  labored  un- 
der, and  the  evacuations  having  occasioned  syncope,  the  medi- 
cine was  suspended  after  two  or  three  grains,  at  most,  had  been 
given.     On  examination,  both  lungs  were  found  to  be  affected  ; 


TREATMENT  OF  PNEUMONIA.  265 

the  right,  over  a  great  extent  and  in  an  advanced  state  of  hepa- 
tization ;  the  left  at  the  roots  and  base,  in  the  stage  of  engorge- 
ment and  Incipient  hepatization.  I  recommended  the  aromatic 
antimonial  infusion,  in  doses  of  a  grain  and  a  half  of  the  tartar 
emetic,  with,  the  syrup  of  poppy.  The  patient  bore  the  medi- 
cine well,  and  took  eighteen  grains  during  the  first  twenty-four 
hours.  It  did  not  occasion  more  purging  than  had  previously 
existed.  During  the  administration  the  patient  recovered  his 
consciousness  ;  the  rhonchus,  sweat  and  oppression  disappeared ; 
and  when  we  saw  him  on  the  following  day,  we  found  him  de- 
cidedly convalescent,  the  stethoscopic  signs  indicating  resolution. 
The  medicine  was  continued  for  some  days,  and  convalescence 
proceeded  without  any  fresh  relapse.  It  was  questioned  whether 
the  sweat  which  existed  at  the  time  when  the  tartar  emetic  was 
administered,  might  not  have  been  critical  in  this  case.  I  cannot 
believe  that  a  perspiration  of  the  kind  described,  coming  on  with 
cerebral  congestion  and  the  tracheal  rhonchus  of  the  moribund, 
can  be  considered  as  critical,  more  particularly  as  it,  as  well  as 
the  other  mortal  symptoms,  passed  off  during  the  use  of  the 
antimony. 

The  above  results  of  my  practice  are  more  favorable  than 
those  of  Rasori's,  lately  published.*  This  may  be  owing  to  two 
causes, — first,  because  auscultation  enables  us  to  ascertain  the 
existence  of  pneumonia  much  quicker  than  we  could  do  from  the 
ordinary  symptoms  ;  and,  secondly,  because,  in  all  probability, 
many  cases  of  simple  pleurisy,  or  of  pleuro-pneumonia  with  pre- 
dominance of  pleurisy,  are  comprehended  by  Rasori  under  the 
name  of  pneumonia, — it  being  impossible  t6  discriminate  these 
different  affections  from  each  other,  without  the  aid  of  ausculta- 
tion. I  have  already  stated  that  we  must  not  expect  equally 
favorable  results  in  the  treatment  of  pleurisy,  as  in  the  treatment 
of  pneumonia,  by  the  tartar  emetic. 

My  cousin,  Dr.  A.  Laennec,  physician  of  the  Hotel  Dieu  of 
Nantes,  has  treated  with  the  tartar  emetic,  during  the  last  two 
years,  forty  cases  of  pleuro-pneumonia.  Of  these,  tsix  proved 
fatal,  three  in  consequence  of  errors  of  regimen  during  conva- 
lescence. Subtracting  these,  then,  the  proportion  of  deaths  will 
be  one  in  thirty .f     Dr.  Hellis  of  Rouen  has  lately  presented  to 

*  Ar.'luv   (m  n.  de  Med.  i    iv      Mars  1827. 

t  An  account  of  seventeen  of  these  cases  is  published  in  the  Journ.  de  Med 
,/<  la  Soc  ilr  la  Loin  Infir.  for  Sep.  1825.  These  are  all  severe  cases,  and  the 
results  are  consequently  more  conclusive  than  those  recorded  in  the  practice  of 
our  author.  One  of  these  cases  (the  tenth)  afforded  a  well  marked  instance  of 
i  .  on  of  pulmonar)  abscess,  and  finely  corroborates  the  statement  advanced  by 
no  in  a  former  note  of  the  necessity  of  the  presence  of  a  peculiar  form  of  ex- 
pe<  h'l.iiiou  in  such  cases  At  the  same  tunc  that  an  imperfect  pectoriloquy 
and  pugs1'11"  rhonchus  were  observed,  the  patient  expectorated  copiously  during 
two  da\«       sputa  at  first  red,  then  resembling  the  washings  of  flesh,  and  finally 

34 


266  TREATMENT  Ol  l'NEUMONIA. 

the  Royal  Academy  of  Medicine,  a  memoir  on  the  treatment  ol 
pneumonia  after  the  method  of  Riverius  and  Stoll,  that  is,  by 
repeated  emetics.*  Of  forty-seven  cases  treated  by  him  he  lost 
only  five,  being  a  proportion  somewhat  less  than  one  in  nine. 
This  result,  although  much  less  favorable  than  that  which  has 
followed  the  use  of  the  tartar  emetic  in  large  doses  in  my  prac- 
tice, is  yet  more  so  than  that  obtained  from  the  employment  of 
bloodletting  and  derivatives,  which  I  have  stated  to  be  one  in 
six  or  eight.  Independently  of  being  less  successful,  the  practice 
of  Riverius  has  not  even  the  merit  of  being  more  gentle  than  that 
of  the  tartar  emetic  in  large  doses;  as  the  repeated  evacuations 
produced  by  it  occasion  great  distress  to  the  patients  and  alarm  to 
the  attendants,  while  such  effects  take  place,  in  the  other  method, 
at  most  only  on  the  two  first  days.  I  continue  the  use  of  the 
medicine  as  long  as  the  tolerance  lasts,  and  while  there  exists  any 
remains  of  the  crepitous  rhonchus.  This  tolerance  I  every  day 
find  to  continue  indefinitely,  in  patients  in  full  convalescence, — 
a  fact  which  is  not  in  accordance  with  Rasori's  theory.  If  I  have 
been  correctly  informed,  he  considers  the  tolerance  as  owing  to 
the  excess  of  stimulus  existing  in  the  system,  and  which  pro- 
duces the  disease  ;  and,  according  to  him,  as  soon  as  the  excess 
of  stimulus  is  destroyed  by  the  contra-stimulant  effect  of  the 
tartar  emetic,  the  tolerance  ought  to  cease.  It  is  certainly  true 
that  after  the  acute  period  of  the  disease,  the  tolerance  dimin- 
ishes or  sometimes  entirely  ceases  ;  but  it  is  more  common  to 
find  the  patient  become  habituated  to  the  medicine,  insomuch 
that,  during  convalescence  and  when  he  has  begun  to  use  as  much 
food  as  in  health,  he  will  take  daily,  without  knowing  it,  six,  nine, 
twelve,  and  even  eighteen  grains  of  the  emetic  tartar.  Putting 
aside  entirely  the  question  of  theory,  1  agree  with    Rasori  in 

yellower  and  almost  purulent ;"  and  when  this  temporary  discharge  had  ceased, 
the  pectoriloquy  became  perfect,  the  cavernous  rhonchus  disappeared  and  was 
replaced  by  a  very  pure  cavernous  respiration. 

Ever  since,  Dr.  Ambroise  Laennec  has  continued  to  treat  pneumonia  with 
tartar  emetic  in  large  doses,  in  the  Hotel  Dieu  of  Nantes  and  in  his  private  prac- 
tice, and  always  with  a  result  as  satisfactory  at  least.  His  plan  is  to  commence 
with  bloodletting,  repeated  according  to  circumstances,  and  not  to  administer 
the  antimony  unless  the  first  bleedings  have  produced  no  marked  amelioration. 
But  if  the  inflammation  occupies  both  lungs  at  the  same  time,  or  if  it  have  al- 
ready reached  the  stage  of  hepatization, — in  other  words,  if  the  physical  si<*ns 
and  general  symptoms  indicate  the  presence  of  a  disease  so  severe  as  to  threaten 
an  unfavorable  result, — he  prescribes  the  tartar  emetic  from  the  very  beginning 
and,  in  imitation  of  Rasori,  proportions  his  doses  to  the  severity  of  the  disease.— 
(M.  L.) 

*This  memoir  has  since  been  published  by  the  author  under  the  title  Clmigiu 
Medicate  dc  I'Hdtel  Dieu  dc  Rouen,  Premiere  Annee.  Paris  1826.  From  this 
work,  and  also  from  another  now  before  me  entitled  Memoir  c  sur  Its  fluxions  dc 
poitrine,  par  Louis  Valentin,  M.  D.  Nancy,  1815  ;  it  would  seem  that  the  prac- 
tice of  giving  emetics  in  pneumonia,  so  much  employed  formerly  by  Stoll  and 
others,  has  still  many  partisans  in  France.— Tran si. 


TREATMENT    OF    PNEUMONIA. 


26" 


opinion,  that  the  tartar  emetic  is  in  general  better  supported,  and 
produces  more  speedy  and  powerful  effects,  in  proportion  as  the 
patient's  constitution  and  the  symptoms  of  the  disease  bear  the 
marks  of  great  plethora  and  high  vital  action ;  but  I  must,  at  the 
same  time,  remark,  that  similar  results  are  occasionally  obtained 
in  debilitated  and  cachectic  subjects,  who  have  not  been  able  to 
bear  bloodletting,  notwithstanding  the  presence  of  an  intense  in- 
flammation. 

Upon  comparing  the  facts  which  I  have  witnessed  in  my  own 
practice,  I  am  convinced  that  the  tolerance  depends  on  the  con- 
currence of  several  circumstances.     In  the  first  place,  the  medi- 
cine in  considerable  doses  is  less  emetic  than  in  small  doses  ;  an 
observation  which  had  been  already  made  by  most  practitioners. 
In  the  second  place,  the  habit  which  accustoms  the  stomach  to 
all  sorts  of  substances  seems  readily*  formed  in  respect  of  this, 
since  we  find  that  vomiting  or  purging  almost  always  follows  its 
administration  on   the  first  day,  and  scarcely  ever  returns  after 
the  second.      A  third   circumstance  which  contributes  much  to 
the  prevention  of  vomiting  is  the  ingestion  of  the  medicine  in  an 
agreeable  vehicle,  somewhat    aromatic  and    moderately  diluted. 
The  intervention  of  a  period  of  two  hours  between  the  doses  also 
contributes  to  the  same  result.     I  have  excited  copious  vomiting, 
by  means  of  the   tartar  emetic  given  in  doses  of  two  grains  in 
three  ounces  of  warm  water,  every  quarter  of  an  hour,  in  the  com- 
mencement of  a  bilious  pneumonia ;  while  the  same  patient  has 
taken  it  on  the  following  and  subsequent  days,  in  doses  of  from 
six  to  nine  grains,  in  the  manner  formerly  mentioned,  without  ex- 
periencing evacuations  of  any  kind.      When   the  flavor  of  the 
orange-leaf  is  disagreeable  to  the  patient,  I  give  the  medicine  in 
some  other  aromatic  infusion,  or  sweetened  emulsion.     When  it 
occasions   too  copious  evacuations,  I  conjoin  with   it,  as  I  have 
stated   above,  a  small   quantity  of  opium, — the  only  corrective  of 
its  operation  in  this  way  that  1  have  been  able  to  find.     Cinchona 
certainly  does  not  act  in  the  same  way,  although  it  has  been  sup- 
posed to  neutralize  the   tartar  emetic  in  the  bolus  ad  quartanam 
of  La  Charite*     There  is  no  doubt  that  bark,  as  well  as  the 
various  vegetable  infusions  usually  combined  with  tartar  emetic, 
more  or  less  decompose  this  medicine  ;   but  this  change  of  state 
does  not  seem  in  any  way  to  affect  its  virtues,  since  we  find  that 
one  or  two  grains  dissolved  in  a   pint  of  vegetable  broth,   lemon- 
ade, decoction   of  tamarinds,  or   even   strong  decoction  of  bark, 
will  produce  very  effective  vomiting :  and  this  result  we  also  ob- 

*  The  bolus  in!  quartanam  used  by  rW  Laeunec  in  Necker  hospital,  the  same 
]  presume  as  that  ol  La  Charite  consists  of  one  grain  ol  the  emetic  tartar  to  the 
dram  of  hark,  made  into  a  mass  by  extract  of  junipei  {Ratter,  Formal  de 
Hdpitaux,  p    L93). — Transl 


268  TREATMENT  OF  PNEUMONIA. 

serve    occasionally  from  the  bolus   above-mentioned,    especially 
when  given  in  small  doses. 

The  practice  above  detailed  is  not  in   reality  so  bold  as  it 
seems  at  first  sight ;  since  only  one,  two,  or  at  most  three  grains 
of  the  tartar  emetic  are  given  at  one  dose, — a  quantity  which 
practitioners  have  been   long    accustomed  to  administer.      The 
medicine  is,  moreover,  given  much  diluted,  and  is  thereby  de- 
prived of  all  the  caustic  properties  which  it  possesses.     These, 
be  it  remembered,  are  but  feeble,  since  we  know  that  it  only  then 
produces  pustules  when  it  is  applied  in  substance,  and  retained 
in  contact  with  the  skin  for  two  or  three  days.*     In  prescribing 
the  medicine,  we  are  careful  not  to  repeat  the  dose  if  the  preced- 
ing has  occasioned  any  ill    consequence,  a  circumstance  which 
will  always  obviate  any  risk  from  its  employment,  in  the  hands 
of  the  prudent  and  active  practitioner.     I  have  been  in  the  daily 
habit  of  employing  the  tartar  emetic  in  the  hospital  since  1816, 
and   more  particularly  since  1821 ;  and  I  do  not  think  that  any 
of  those  who  have  observed  my  practice,  have  ever  witnessed  any 
ill  effect   of  consequence,  from  its   administration.     And  I  can 
give  a  like  report  of  its  effects  in  my  private  practice,  with  this 
single  exception,  that  I  have  observed,  in  the  latter,  vomiting  to 
be  more  frequent  than  in  the  hospital.     This  difference  of  result 
has  appeared  to  me  owing  to  the  patients  being  informed  by  the 
nurses  or  their  friends,  that  they  were  taking  tartar  emetic,  a 
thing  which  I  have  always  been  anxious  to  conceal  from  them. 

I  have  employed  the   tartar  emetic  in   large  doses,  in   many 
other  diseases  besides  pneumonia,  particularly  in  other   inflam- 
matory affections,  and  in  fluxes  and  congestions  of  an  active  or 
hypersthenic  kind.     Convinced  of  the  importance  of  this  mode  of 
treatment,  and  of  the  administration  of  many  other  medicines  in 
much  larger  doses  than  are  usual,  I  think  it  right  to  give  in  this 
place  a  brief  account  of  the  principal  results  which  I  have  ob- 
tained in  this  way.     1.  Although  emetic  tartar  answers  in  gene- 
ral well  in  inflammatory  and  sthenic  diseases,  all  inflammations 
do  not  yield  to  it  in  the  same  degree.     2.  In  the  inflammations 
of  serous  membranes,  and  particularly  in  pleurisy,  the  remedy  is 
rarely  heroic,  and  never  unless  the  disease  is  very  acute.     It  in- 
deed reduces  speedily  the   inflammatory  action ;    but  when    the 
fever  and  pain  have  ceased,  the  effusion  does  not  always  disap- 
pear more  rapidly  under  the  use  of  the  tartar  emetic,  than  with- 
out it.     I  have  not  yet  had  an  opportunity  of  trying  the  effect  of 
this  medicine  in  peritonitis,  and  indeed  I  should  feel  unwilling  to 
do  so,  on  account  of  the  admirable  effects  which  I  have  found 

*  A  strong  solution  will  have  the  same  effect ;  and  this,  and  still  more  tin 
medicine  in  substance;  will  commonly  produce  its  characteristic,  irritation  much 
sooner  than  is  stated  in  the  text.—Trnnsl. 


TREATMENT  OP  PNEUMONIA. 


269 


from  another  kind  of  practice,  that,  namely,  of  mercurial  inunc- 
tion, carried  rapidly  to  salivation,  after  one  or  two  applications 
of  leeches.     In  a  case  which  presented  all  the  symptoms  of  acute 
arachnitis,  I  obtained  a  complete  cure  by  the  tartar  emetic  in  a 
period  of  forty-eight  hours.*     3.  In  three  instances,  and  nearly 
in  the  same  space  of  time,  I  observed  all  the  symptoms  of  acute 
hydrocephalus  disappear  under  the  use  of  the  tartar  emetic.     In 
two  of  these,  the  cerebral  affection  supervened  in  the  course  of 
continued  fever.     The  third  occurred  in  the  person  of  a  young 
man,  who,  after  long  watching,  was  seized  with  vertigo  and  other 
signs  of  cerebral  disorder.     For  these  complaints  he  had  leeches 
and  cold  lotions  applied,  but  without  benefit :   at  the  end  of  two 
months  he  fell  into  a  fit,  and,  after  five  days,  was  brought  into  the 
Necker   Hospital.      At  this   time   lie    was   insensible,   motion- 
less, extremely  pale,  and  with  the  pupils  much  dilated.     Leeches 
were  ordered  to  the  temples,  but  only  eight  fixed,  and  drew  little 
blood.     I   prescribed,  at  the  same   time,  twelve  grains   of  the 
tartar  emetic  to  be  taken  in  twenty-four  hours.     On  the  following 
day  he  could  move  and  speak  a  little.     I  then  ordered  fifteen 
grains  of  the  medicine,  and   found  him  on  the  succeeding  day, 
much   better:    although  still  very    weak,  he  had  regained  en- 
tirely both  sense  and  motion,  and  the  pupil  was  now  hardly  at 
all    dilated.     As    he   had    no    evacuation  of  any  kind,  I    pre- 
scribed eighteen  grains  of  the  tartar  emetic  and  also  some  food. 
On  the  6th  day  he  was  completely  convalescent,  and  had  re- 
covered his  appetite.     He  continued  in  perfect  health.     I  for- 
merly stated  that  I  have  found  this  medicine  useful  in  the  suffo- 
cative catarrh  of  adults,  and  in   oedema  of  the  lungs,  especially 
when  these  affections  are  combined  with  slight  pneumonia.     Dr. 
Ambrose  Laennec  has  effected,  by  the  same  means,  a  cure  of  a 
very  violent  idiopathic  tetanus,  in  the  space  of  a  very  few  days.f 
I  had  lately  under  my  care  an  acute  inflammation  of  several  of  the 
veins  in  .the  arm,  treated  in  the  same  way.     The  basilic  vein  was 
greatly  enlarged,  hard  as  a  cord,  and  its  course  indicated  on  the 
skin  by  a  line  of  a  deep  red  color.     The  fore-arm  was  very  hard, 
enormously  swollen,  and  presenting  a  mixed  character  of  oedema 
and  erysipelas.     It  was  generally  pale  and  shining,  but  in  many 
places  it  was  of  a  copper  color  and  very  sensible  to  the  touch. 
There  was  high  fever,  but  the  head  was  not  affected.     I  ordered 
twenty-four  leeches  to  be  applied  to  the  vulva,  and  six  grains  of 

*  Revue  Med.  Juin,  1823,  p.  344.  But  the  efficacy  of  the  antimony  maybe 
here  questioned,  as  the  improvement  did  not  occur  until  after  bloodletting  from 
the  foot.— (M.  L.) 

t  This  case  is  reported  in  Bayle's  Bib.  de  Tkerap.  (t.  i.  p.  298.)  Two  other 
cases  of  idiopathic  tetanus  have  been  since  treated  by  Dr.  A.  Laennec,  in  the 
same  manner  and  with  like  success.  (Sec  Bib.  de  Tkerap.  p.  50G,  and  Revue 
Med.  Oct.  1628.)— (M.  L.) 


270  TREATMENT  OF  PNEUMONIA. 

the  emetic  tartar  to  be  administered.     On  the  following  day  the 
inflammation   and   fever  had  subsided,  and  at  the  end   of  three 
days,  complete  resolution  had  taken  place.     This  cure  will  no 
doubt  appear  remarkable  to  such  practitioners  as  have  had  occa- 
sion to  see  cases  of  acute  phlebitis,  and  who  know  how  rarely  and 
difficultly  it  is  cured  by  loss  of  blood.*     In  some  cases  of  acute 
chorea,  I  have  found  the  medicine  beneficial,  but  not  in  an  ex- 
treme degree.     This  is  the  only  nervous  affection  in  which  I  have 
made  trial  of  the  practice  and  only  in  cases  which  appeared  con- 
nected with  a  congested  state  of   the  brain  or  spinal  marrow. 
Articular  rheumatism,  is,  next  to  pneumonia,  the  inflammatory 
disease  in  which  the  tartar  emetic  has  appeared  to  me  the  most 
efficacious.     The  usual  duration  of  this    complaint,  treated  by 
the  antimony,  is  from  seven  to  eight  days ;  and  I  need  hardly  say 
that,  when  treated  by  bleeding,  or  on  the  expectant  system,  it 
lasts  from  one  to  two  months.     This  remedy,  however,  succeeds 
less  perfectly  when  muscular  rheumatism  is  combined  with  the 
articular.     Occasionally  I  have  found  a  relapse  of  the  articular 
inflammation  to  take  place  during  the  continuance  of  the  anti- 
mony ;  and  in  two  cases  I  was  obliged  to  leave  it  off  from  not 
being  able  to  effect  the  tolerance. — In  some  cases  of  severe  oph- 
thalmia and  angina,  1  have  obtained  as  speedy  cures  as  in  pneu- 
monia.!— I  have  not  hitherto  made  use  of  the  emetic  tartar  in 
simple  inflammation  of  the  intestinal  mucous  membrane ;  but  in 
cases  of  pneumonia  or  articular  rheumatism,  I  have  not  been  de- 
terred from  using  it,  by  the  presence  of  redness  of  the  tongue, 
considerable  part  of  the  epigastrium  or  abdomen  augmented  by 
pressure,  or  diarrhoea  and  tenesmus.     In  such  cases  I  have  ob- 
served the  symptoms  just  mentioned  to  disappear  under  the  in- 
fluence of  the  remedy,  as  speedily  as  those  of  the  principal  dis- 
ease.    In  a  word,  I  do  not  consider  the  gastro-enteritis  of  fevers 
as  contra-indicating  the  use  of  the  emetic  tartar.     And   in  fact, 
do    we  not    find   many  external    inflammations,  opthalgiias    for 
instance,    yield  much  sooner  to  the    use  of  gently  stimulating 
topical  applications  than  to  bleeding  and  emollients  '/$     The  con- 

*  See  a  full  account  of  this  case  in  the  Revue  MM.  for  Oct.  1825. 

t  M.  Baylc  in  his  Bib.  de  Thcrap.  (t.  i.  p.  23!),)  has  inserted  a  note  commu 
nicated  by  me,  giving  an  account  of  some  of  the  facts  referred  to  in  the  texl 
I  will  only  here  notice  those  which  relate  to  articular  rheumatism.  Thirteen 
cases  were  treated  with  the  tartar  emetic  with  the  following  results: — in  one, 
the  remedy  was  injurious;  in  two,  it  was  inefficacious;  in  two,  ils  success  was 
doubtful;  in  eight,  it  was  evidently  useful.  These  results,  although  interesting, 
only  afford  an  approximative  view  of  the  practice  of  Laennec.  He  treated  in 
the  same  way  all  the  cases  of  rheumatism  admitted  into  his  clinic,  (with  120 
beds,)  in  the  Necker,  in  1822,  and  the  first  three  months  of  1823;  and  if  J  had 
kept  more  accurate  notes,  the  number  of  observations  might  have  been  much 
greater. — (M.  L.) 

\  In  a  former  note  I  have  referred  to  the  not  infrequent  complication  of  pneu 
moniawith  gastric  inflammation,  and  of  the  impropriety  of  exhibiting  purga- 


TREATMENT  OF  PNEUMONIA.  271 

tra-indications  to  the  use  of  this,  as  of  all  other  medicines,  ought, 

tivcs  in  such  Cases.  My  objection  must  necessarily  be  still  stronger  and  more 
valid  (if  at  all  valid)  against  tlie  use  of  tartar  emetic  in  large  doses;  and  I  must, 
therefore,  enter  my  protest  against  the  treatment  recommended  in  the  text  in 
all  instances  of  this  complication.  I  have  already  hinted  at  the  marked  dislike, 
I  might  almost  say  unjustifiable  prejudice,  of  our  author  to  the  doctrines  of 
Broussais;  and  1  fear  I  must  be  so  uncharitable  as  to  receive  with  some  degree 
of  caution  not  only  his  judgments,  but  even  the  statements  of  his  observation, 
when  these  bear  very  directly  upon  the  favorite  doctrines  of  his  rival.  I  am 
very  far  from  assenting  to  the  system  of  Broussais  as  aeode  of  medical  doctrine; 
and  am  ready  to  admit  the  absurdity  of  not  a  few  of  his  opinions,  and  the  im- 
propriety of  a  good  deal  of  his  practice  in  several  diseases;  at  the  same  time  I 
feel  it  due  to  him  to  say  that  I  consider  practical  medicine  under  deeper  obliga- 
tions to  him  than  to  any  other  individual  who  has  appeared  during  the  present 
century,  perhaps  during  the  last  fifty  years.  His  great  merit  consists,  as  is  well 
known,  in  having  almost  discovered,  certainly  in  having  clearly  demonstrated, 
the  precise  nature  and  extreme  frequency  of  inflammation  or  irritation  of  the 
mucous  membrane  of  the  stomach  and  bowels,  and  in  having  pointed  out  the 
vast  importance  and  indeed  necessity,  of  attending  to  this  in  all  cases  where  it 
exists,  in  order  to  ensure  any  chance  of  success  from  the  application  of  our 
remedial  measures.  The  best  proof  of  the  value  of  M.  Broussais's  doctrines  is 
found  in  the  fact  of  their  having  modified,  in  a  greater  or  less  degree,  the  prac- 
tice of  the  physicians  in  every  country  of  Europe  ;  and  it  is  obvious  to  every 
one  that,  even  in  England,  where  much  opposition  has  been  shown  to  them, 
they  are  at  this  moment  influencing  the  conduct  of  most  of  those  who  are  loud- 
est in  decrying  them.  In  respect  of  the  administration  of  the  emetic  tartar  in 
pneumonia  complicated  with  gastric  disorder,  I  should  say  that  it  requires  the 
utmost  caution  generally,  and  the  greatest  attention  to  each  particular  case,  in 
order  to  guard  against  producing  great  mischief  by  it.  In  many  of  those  cases 
of  gastric  complication  recorded  by  Stoll,  Riverius,  Hellis,  and  others,  where 
the  affection  consists  rather  in  a  loaded  condition  of  the  stomach,  duodenum 
and  liver,  and  a  vitiated  state  of  their  respective  secretions,  than  in  inflamma- 
tion or  high  irritation  of  the  mucous  membranes,  no  doubt  the  emetic  tartar  may 
be  valuable,  at  all  events  as  an  emetic ;  but  where  evident  signs*  of  the  other 
condition  of  parts  exist,  we  cannot  administer  this  remedy  without  imminent 
danger  of  augmenting  the  evils  we  are  attempting  to  alleviate.  That  even  in 
these  latter  cases,  the  emetic  tartar  is  sometimes  useful,  I  do  not  deny;  but  I 
believe  Broussais's  opinion  on  this  point  will  be  found  to  be  generally  correct : 
he  says,  speaking  of  emetics  in  simple  inflammatory  affections  of  the  stomach, 
"  leur  eft'et  est  incertain  dans  les  cas  legers ;  et  dans  les  graves,  ils  sont  tojours 
danger enx,  parcequ'ils  ne  manquent  jamais  d'augmenter  l'inflammation  qu'ils 
n'ont  pas  reussi  a  enlever."  Propos.  dc  Med.  Prop,  eclxxxvii.  But  my  princi- 
pal object  at  present  is  to  call  the  attention  of  practitioners  to  the  frequent  co- 
existence of  gastric  affections  with  pneumonia  in  this  country,  and  to  point  out 
the  absolute  necessity  in  such  cases  of  treating  both  diseases  at'the  same  time. 
In  the  simple  diseases  we  shall  generally  find  our  bleedings  from  the  arm  and 
our  tartar  emetic,  according  to  the  French  phrase,  heroic  ;  while  in  the  compli- 
cated affection,  we  shall  find  these  means,  if  not  injurious,  at  least  inefficacious, 
if  we  fail  to  attack  the  gastric  affection  with  leeches  to  the  epigastrium,  saline 
refrigerants,  mucilaginous  diluents,  &c,  and  if  we  do  not  forbid  the  ingestion 
of  stimulant  purgatives  and  other  irritants,  at  least  for  a  season.  I  cannot  con- 
clude this  note  without  particularly  calling  the  attention  of  practitioners  to  some 
most  valuable  practical  remarks  on  the  complication  now  under  consideration, 
contained  in  the  Appendix  to  Dr.  Philip's  excellent  Treatise  on  Indigestion. 
(See  particularly  pages  77.  81 — 85.)  These  remarks,  I  doubt  not,  will  be  novel 
to  the  great  majority  of  his  readers ;  and  will  probably  be  received  with  more 
consideration  from  being  the  result  of  his  own  practical  observation.  At  least, 
I  conclude  from  his  having  made  no  allusion  to  any  continental  writers,  that  the 
author  is  unacquainted  with  their  previous  observations  in  this  particular  case. 
My  own  attention  was  first  called  to  this  important  subject  by  my  most  intelli- 
gent and  observant  friend,  Dr.  James  Clark,  formerly  of  Rome,  now  of  London. 
—  Transl. 


272  TREATMENT  OF  PNEUMONIA. 

in  my  opinion,  to  be  founded  en  experience  alone.  The  chief  of 
these  contra-indications  is,  defective  tolerance,  announced  by  too 
copious  evacuations.  Some  diseases,  apparently  -  as  active  and 
inflammatory  as  those  above  mentioned,  do  not  give  way  under 
the  use  of  the  emetic  tartar  even  when  it  is  the  best  supported. 
I  formerly  stated  haemoptysis  to  be  one  of  them ;  and  to  this  I 
may  add  apoplexy,  gout,  erysipelas,  and  most  chronic  inflam- 
mations, except  some  of  those  which  have  degenerated  from  the 
acute  to  the  chronic  state.  In  cases  of  this  kind,  I  have  seen 
the  medicine  supported  perfectly  well,  in  doses  of  from  nine  to 
twelve  grains  a  day,  without  any  obvious  result.  In  some  cases 
of  apoplexy  I  have  gradually  increased  the  dose  to  a  dram  and  a 
half,  without  any  sensible  effect ;  while,  in  others,  I  have  seen 
the  symptoms  of  cerebral  compression  disappear  in  a  few  hours, 
and  all  marks  of  paralysis  pass  off  rapidly.  This  fact  of  com- 
plete tolerance  existing  without  any  effect  on  the  disease,  is 
strongly  against  the  theory  of  Rasori  and  Tommasini.  In  my 
opinion  it  is  enough  for  the  practical  physician  to  be  able  to 
appreciate  the  effects  of  a  remedy,  and  to  determine  experimen- 
tally the  cases  in  which  it  was  useful.  At  the  same  time,  if  in  the 
present  instance  it  is  thought  of  use  to  ascertain  the  mode  of 
action  of  the  remedy,  I  should  say  that  its  most  constant  effect 
is  the  rapid  resolution  of  inflammation,  and  sometimes  the  equally 
speedy  absorption  of  the  inflammatory  effusion.  I  have  thus 
seen,  in  the  case  'of  articular  rheumatism,  a  well-marked  fluctu- 
ation in  the  knee-joint  disappear  in  the  course  of  six  hours.  In 
such  cases  we  cannot  attribute  the  result  to  derivation,  since  this 
is  never  more  marked  than  when  there  has  existed  neither  vomit- 
ing nor  any  other  kind  of  evacuation.  Sweats,  it  is  true;  and  also 
a  copious  flow  of  urine,  sometimes  accompany  the  resolution  :  but 
these  are  by  no  means  constant.  For  these  reasons,  it  appears 
to  me  that  the  only  way  in  which  we  can  explain  the  action  of 
this  medicine,  in  the  present  state  of  our  knowledge,  is,  by  ad- 
mitting "that*  it  increases  the  activity  of  the  interstitial  absorp- 
tion, particularly  when  there  is  present  in  the  system  an  excess  of 
energy,  tone,  or  plethora.  I  ought  further  to  remark  in  this 
place,  that,  after  having  cautiously  tried  the  effect  of  this  medi- 
cine in  a  few  cases  of  dropsy  of  an  asthenic  character,  particularly 
in  ascites  and  anasarca,  the  consequence  of  disease  of  the  heart  or 
liver,  without  any  beneficial  result,  I  have  abandoned  the  prac- 
tice in  such  circumstances.  On  the  other  hand,  in  a  case  of 
acute  anasarca  of  the  extremities  complicating  a  similar  affection 
of  (he  lungs,  I  found  the  practice  completely  successful ;  and  lam 
of  opinion  that  it  would  be  frequently  useful  in  the  anasarcous 
swellings  produced  by  measles  and  scarlatina.* 

Since  its  first  introduction   into  the  practice  of  medicine,  antimony,  in   one 


TREATMENT    OF    PNEUMONIA. 


273 


1  have  made  trial,  in  large  doses,  of  some  other  medicines, 
which,  according  to  the  statements  of  the  Italian  Journals,  would 

form  or  other,  has  been  very  generally  and  extensively  used  by  the  physicians 
of  every  nation  in  Europe.  Like  all  powerful  remedies,  it  has  been,  at  differ- 
ent times,  the  subject  alike  of  commendation  as  of  reprobation,  equally  unmeas- 
ured. When  first  introduced  by  Paracelsus,  it  was  considered  as  an  antidote 
to  the  most  terrible  diseases,  and  was  used  and  esteemed  as  such  in  the 
plague  of  1562.  Only  four  years  after  this,  however,  it  was  declared  poison- 
ous by  the  Parliament  of  Paris,  and  its  use  interdicted  under  severe  penalties. 
Further  and  more  extensive  experience  restored  the  remedy  to  its  legiti- 
mate rank  in  the  materia  medica;  and  since  the  middle  of  the  last  century, 
more  especially,  it  has  been  very  generally  and  extensively  used-  in  febrile 
and  inflammatory  diseases,  principally  in  the  form  of  emetic  tartar.  In  proof 
of  this  we  may  refer  to  almost  every  practical  writer  during  the  last  sixty  or 
seventy  years.  Among  the  most  eminent  of  those  who  used  it  extensively  dur- 
ing the  last  century  may  be  mentioned  Brendel,  Richter,  Hirschel,  Stoll, 
Gmelin,  Riviere,  Pelligrini,  Huxham,  Pringle,  Cullen,  Withers,  &c.  <fcc. 
Some  of  these  used  the  medicine  chiefly  as  an  emetic,  but  most  of  them  as  a 
diaphoretic,  and  in  doses  sufficient  to  produce  nausea.  The  partiality  of  Dr. 
Cullen  to  this  medicine  is  well  known;  and  it  seems  at  present  probable  that 
this  partiality  will  henceforward  be  as  much  cited  to  his  praise,  as  it  has  been 
often  hitherto  adduced  to  his  discredit.  There  can  be  no  doubt,  however,  that  it 
is  to  the  Italian  physicians,  and  especially  Rasori,  that  we  are  indebted  for  the  in- 
troduction of  the  tartar  emetic  in  large  doses,  as  a  cure  for  inflammatory  diseases. 
The  author  just  mentioned  first  used  it  in  the  epidemic  fever  of  Genoa,  in  the 
year  1799  or  1800,  giving  it  in  doses  of  four,  six,  eight,  or  more  grains  in  the 
course  of  the  day,  in  any  watery  vehicle  the  patient  preferred.  (See  Storia  della 
Febbrc  petcchiale,  <fcc.  &c.  di  G.  Rasori.  Terza  edit.  Milano,  1813,  p.  38.)  Soon 
after  this  period,  the  author  appears  to  have  employed  this  remedy,  yet  more 
extensively  and  in  larger  doses,  in  pneumonia.  In  his  memoir  on  this  disease, 
referred  to  by  Laennec,  as  translated  into  French  by  Dr.  Fontaneilles,  and  pub- 
lished in  the  Archives  Gen.  de  MM.  for  1824,  he  gives  the  result  of  his  clini- 
cal practice  with  the  tartar  emetic  in  pneumonia,  in  the  years  1808,  9,  10.  His 
general,  method  was  to  commence  the  medicine,  usually  after  one  or  more 
bleedings,  but  sometimes  without  any  previous  depletion  :  "  I  seldom  begin  (he 
says)  with  less  than  twelve  grains  during  the  day,  and  as  many  during  the  night. 
It"  I  find  the  disease  already  advanced,  I  begin  with  a  scruple  or  half  a  drachm, 
and  go  on  daily  increasing  the  dose,  until  it  amounts  to  a  drachm,  or  even 
several  drachms,  in  the  course  of  the  twenty-four  hours."  The  result  of 
this  practice  was  on  the  whole  successful ;  the  number  of  deaths  being  only  one 
hundred  and  seventy-three  out  of  eight  hundred  and  thirty-two  cases  of  pneu- 
monia treated  by  him  ;  or  about  twenty-two  per  cent,  in  the  civil  hospital,  and 
fourteen  per  cent,  in  the  military.  It  would  appear,  however,  from  the  testi- 
mony of  others  that  Rasori's  practice  has  been  far  from  being  always  so  success- 
ful. Wagner  informs  us  (Darstellung  und  Kritik  der  Italianischen  Lehre  vom  Con- 
trastimulus.  Berlin,  1819,)  that  out  of  thirteen  cases  of  pneumonia,  no  less  than 
seven  died — victims,  according  to  this  writer's  belief,  more  to  the  practice  than 
the  disease.  In  1808,  M.  Fontaneilles,  the  translator  of  Rasori's  essay  sent  an 
account  of  this  author's  practice  to  the  Societe  de  Medicine  de  Paris,  in  a  memoir 
which  was  afterwards  published  in  the  year  1819,  in  vol.  xlii.  of  the  "  Jlnnales 
Cliniquts  dc  Montpelier."  Since  the  introduction  of  it  by  Rasori,  the  emetic 
tartar  has  been  in  very  general  use  by  the  Italian  physicians,  as  sufficient- 
ly appears  from  the  writings  of  Brera,  Tommasini,  Fanzago,  Borda,  Rubini, 
Gentile,  Pozzi,  Tozetti,  &c.  Tommasini  states,  that  out  of  one  hundred  and  fif- 
teen cases  of  pneumonia,  treated  with  tartar  emetic,  (conjointly  with  bleed- 
ing, &c.)  only  fourteen  died  ;  see  his  works — ';  Delia  nouvadott.  Ital."  Bologna, 
1816  ;  "  Delle  peripneumonie,  injlammatorie  c  del  curarle  principalmentc  col  tarta- 
rostibialo."  Bologna,  1817;  Prospctto  dei  Resulti,  &,e."  Pisa,  1823  ;  and  Dr.  Gen- 
tile of  the  Naples  says  he  lost  only  one  in  forty.  In  the  Bibliotluque  Universellc 
oi  Geneva,  for  June,  1822,  there  is  a  memoir  by  31  Peschier  on  the  use  of  this 

35 


274  TREATMENT  OF  PNEUMONIA. 

seem  to  be  placed  by  Rasori  and  Tommasini  nearly  on  the  same 
footing  as  emetic   tartar ;  such  as  the  kermes,  the  yellow  siri- 

remedy  in  the  same  disease,  in  which  lie  gives  the  most  surprising  account  of 
its  success.  His  mode  of  using  it  was  to  dissolve  six,  twelve  or  fifteen  grains, 
in  six  ounces  of  water,  and  to  give  a  table-spoonful  every  second  hour,  day  and 
night,  together  with  an  aperient  ptisan  ;  adding  occasionally,  according  to  cir- 
cumstances, aether,  nitre,  or  tincture  of  opium.  He  usually  began  with  the 
smaller  dose,  increasing  by  three  grains  daily,  but  never  exceeding  fifteen  in  the 
twenty-four  hours.  In  this  manner  he  had  treated  all  his  cases  of  pleurisy  and 
pneumonia  for  the  preceding  five  years,  and  according  to  his  account,  had  cured 
almost  all  of  them,  in  a  short  space  of  time,  without  bloodletting,  and  generally 
without  even  blisters  ! — Much  about  the  same  time  that  the  Italian  treatment 
was  embraced  by  M.  Laennec  in  France,  Dr.  Balfour  appears  to  have  adopted 
it  in  Edinburgh,  and  to  have  followed  it  up  with  vigor  and  success.  The  results 
of  his  practice  were  first  given  to  the  public  in  1818,  and  excited  considerable 
interest;  as  may  be  inferred  from  the  appearance  of  an  enlarged  edition  of  his 
work  next  year  under  the  title  of  <;  Illustrations  of  the  power  of  emetic  tartar 
in  the  cure  of  fever,  inflammation  and  asthma,  and  in  preventing  consumption 
and  apoplexy."  Dr.  Balfour's  general  practice  appears  to  have  been  to  give  the 
medicine  in  doses  of  one-third  or  one-half  of  a  grain  every  hour,  usually,  but  not 
always  combined  with  an  aperient  neutral  salt.  The  remedy  in  the  hands  of  ibis 
author  seems  to  have  been  productive  of  very  similar  effects  to  those  recorded 
by  the  continental  physicians.  Some  of  his  cases  afford  very  striking  and  une- 
quivocal proofs  of  the  great  efficacy  of  the  practice  ;  although  I  suspect  a  few  oi 
his  readers  will  coincide  with  him  in  some  of  his  conclusions.  Shortly  after  the 
publication  of  Dr.  Balfour's  work,  the  practice  recommended  in  it  was  adopted 
by  Mr.  Jeffreys,  in  several  surgical  diseases  ;  and  in  his  work  entitled  "  Casts  in 
Surgery,''  published  in  1820,  seventeen  cases  of  external  local  inflammations  are 
given,  treated  by  the  tartar  emetic  with  distinguished  success.  The  practice  ap- 
pears to  have  become  much  more  generally  known  and  adapted,  more  especially  in 
Germany,  since  the  publication  of  Peschier's  memoir;  although  neither  this  au- 
thor, nor  the  French  or  English  writers  already  mentioned,  can  lay  any  claim  to 
the  discovery  or  invention  of  the  method,  the  honor  of  which  seems  justly  due  to 
Rasori.  In  Hufelands'  "  Journ.  derprakt.  Heillcunde"  for  March,  1823,  Dr,  Wolff, 
of  Warsaw,  gives  an  account  of  his  great  success  from  this  method  ;  and  a  simi- 
lar report  is  made  by  Dr.  Wesener,  in  the  same  Journal  for  May,  1824.  In  a 
thesis  by  Dr.  Burghardt,  (printed  at  Berlin,  in  1824,)  "  De  tartari  emetici  in  pec- 
toris inflammationibus  usu."  the  efficacy  of  the  remedy  is  considered  as  fully 
proved,  and  several  original  cases,  illustrating  its  powers,  are  given.  To  the 
body  of  evidence  above  referred  to,  together  with  that  adduced  by  Laennec  in 
the  text,  it  is  hardly  necessary  that  any  thing  should  be  added,  to  ensure  the 
reader's  assent  to  the  great  powers  of  emetic  tartar  in  subduing  inflammation  of 
the  lungs.  I  think  it  right,  however,  to  state  that  my  own  experience  of  its 
effects,  though  limited,  is  decidedly  in  favor  of  the  remedy.  During  the  last 
six  years  I  have  used  it  (after  pretty  copious  venesection,  however)  in  a  good 
many  cases  of  pneumonia,  and  in  a  few  of  acute  rheumatism.  In  all  these 
cases  the  termination  was  favorable,  but  I  know  too  well  the  extreme  difficulty 
of  obtaining  certain  conclusions  in  practical  medicine,  to  feel  justified  in  assert- 
ing my  positive  belief,  that  the  cure  was  in  all  the  effect  of  the  tartar  emetic. 
I  cannot  be  mistaken,  however,  in  stating  the  result  of  my  own  experience  to 
be,  that,  in  pure  pneumonia,  the  tartar  emetic,  in  large  doses,  is  the  most  certain 
and  powerful  remedy  we  possess,  excepting,  perhaps,  bloodletting ;  and  that 
in  many  cases  it  is  capable  of  producing  the  most  striking  and  beneficial  effects 
when  bloodletting  is  no  longer  applicable.  Indeed  I  must  say,  that  I  regard 
this  remedy,  in  the  proper  cases,  as  yielding  to  no  single  therapeutic  agent  in 
potency  of  effect.  Like  those  of  quinine  and  a  very  minute  minority  of  other 
medicines,  its  happy  effects,  unequivocally  demonstrated,  tend  to  keep  alive  in 
the  mind,  of  the  philosophic  physician,  that  faith  and  confidence  in  the  powers 
of  his  art,  which  are  in  constant  jeopardy  from  the  loose  observations,  inconse- 
quent reasonings,  and  overweening  pretensions  of  every-day  practitioners. 
In  no  instance  but  one  have  I  seen  any  bad  effects  from  it ;  and  in  this,  it  was 


TREATMENT    OF    PNEUMONIA. 


275 


piiuret  of  antimony,  nitre  and  digitalis.  Of  the  two  latter  I 
shall  speak  when  I  come  to  treat  of  pleurisy.     Of  the  antimonial 

incautiously  administered  without  due  reference  to  the  co-existence  of  gastric 
irritation.  The  only  objection  to  its  use  appears  to  me  to  be  the  severity  of  its 
operation,  previously  to  the  establishment  of  the  tolerance.  In  several  cases  I 
have  found  the  tolerance  to  exist  from  the  first;  in  the  majority,  it  was  speedily 
established ;  in  others,  distressing  nausea  continued  for  a  good  many  hours,  and 
in  most  of  them  there  were  also  both  vomiting  and  purging.  After  a  short  time, 
however,  all  the  obvious  effects  of  the  medicine,  if  we  except  sweating,  ceased, 
and  returned  no  more,  although  it  was  continued  for  several  days  afterwards. 
Of  the  mode  of  action  of  this  medicine  on  the  system  in  producing  the  resolu- 
tion of  inflammation,  there  are  many  opinions  advanced  by  various  authors; 
and  it  would  be  no  very  difficult  matter  to  propound  more,  equally  plausible  at 
least.  The  theory  of  Rasori  is  not,  I  imagine,  very  different  in  reality  from  that 
of  Basil  Valentine,  (or  whoever  was  (he  author  of  the  Curris  Triumphalis  of 
Antimony.)  who  says  that  although  in  itself  antimony  is  a  poison,  yet  that  hav- 
ing the  power  to  drive  out  the  poison  of  the  disease,  it  thereby  becomes  a  most 
peerless  remedy;  and  I  am  not  sure  that  Dr.  Balfour's  aphorism  ("increased 
arterial  or  inflammatory  action,  is  incompatible  with  the  presence  of  emetic 
tartar  in  the  system.")  tells  us  any  thing  more  than  what  we  knew  (or  believ- 
ed) before,  viz.  that  the  remedy  cured  the  disease. 

In  the  new  edition  of  the  present  treatise,  Dr.  Mer.  Laennec,  after  referring 
to  the  vast  body  of  evidence  now  collected  on  the  subject  of  the  effect  of  tartar 
emetic  in  pneumonia,  naturally  asks  how  it  has  happened  that  so  large  an  ex- 
perience has  not  established  with  certainty  the  good  and  evil  of  this  treatment  ? 
This  he  attributes  to  the  following  causes  :  because,  on  the  one  hand,  the  parti- 
sans of  the  practice  have  announced  their  statements  too  enthusiastically,  con- 
cealing or  depreciating  the  effects  attributable  either  to  nature  or  to  other  reme- 
dies employed  simultaneously,  and  because  they  have  not  taken  proper  account 
of  the  severity,  stage,  and  other  circumstances  of  the  cases  ;  and  because,  on 
the  other  hand,  the  opponents  of  the  practice  have  greatly  overrated  the  ill 
effects  which  it  may  have  had,  in  some  cases,  on  the  digestive  organs.  "How- 
ever, (continues  Dr.  Mer.  Laennec,)  no  honest  man  who  carefully  weighs  all 
the  evidence,  can  hesitate  to  assent  to  the  truth  -of  the  two  following  proposi- 
tions :  1.  Emetic  tartar  may  be  given,  in  doses  of  from  six  grains  to  a  drachm  in 
twenty-four  hours,  in  pneumonia,  without  producing,  as  might  have  been  ex- 
pected, any  inflammation  of  consequence  in  the  gastro-intestinal  mucous  mem- 
brane;  2.  Tartar  emetic  in  large  doses  given  singly  or  in  conjunction  with 
bloodletting  (and  most  certainly  if  so  combined)  is  of  undoubted  efficacy  in 
pneumonia,  and  almost  always  brings  about  a  cure,  which  mere  antiphlogistic 
remedies,  singly  or  combined  with  other  measures  in  ordinary  use,  could  not 
have  effected." 

I  find  from  a  note  to  Dr.  Williams's  Treatise  on  pneumonia  in  the  Cyclopadia 
of  Pract.  Med.  that  Dr.  Marryat  of  Bristol,  who  died  in  1793,  is  justly  entitled 
to  the  honor  of  priority  in  the  administration  of  the  tartar  emetic  in  large  doses, 
as  the  following  extract  from  the  last  edition  of  his  "  Thereaputics"  published 
in  1790  (the  first  edition  in  English  was  published  in  1775)  unequivocally 
proves  : — "  Any  fever  (says  Dr.  Marryat)  may  be  soon  extinguished  by  the  use 
of  the  following  powders  :— Take  of  tartarized  antimony  five  grains,  white  sugar 
(or  nitre)  a  drachm  ;  let  them  be  well  rubbed  in  a  glass  mortar,  and  divided 
into  six  powders;  one  to  be  taken  every  three  hours,  notwithstanding  the  nau-g 
sea,  the  first  may  possibly  occasion.  If  these  are  taken  (which  is  commonly 
the  case)  without  any  manifest  inconvenience,  let  there  be  seven  grains  in  the 
next  six  powders;  and  in  the  next  ten.  Here  I  beg  to  retract  what  I  said  in 
some  former  edition  of  this  work,  viz.  that  till  sickness  and  vomiting  were  ex- 
cited, this  noble  medicine  was  not  to  be  depended  upon.  For  I  have  since  seen 
many  instances  wherein  a  paper  has  been  given  every  three  hours,  (of  which 
there  hare  been  ten  grains  in  six  powder?,)  without  the  least  sensible  operation, 
either  by  sickness,  stool,  sweat,  or  urine,  and  though  the  patients  had  been  un- 
remittedly  delirious  for  more  than  a  week,  with  subsultus  tendinum  and  all  the 
appearance  of  hastening  death,  they  have  perfectly  recovered  withcut  any  med- 


•276  TREATMENT    OF    PNEUMONIA. 

preparations,  I  may  say  that  I  have  not  found  them  of  much 
power  even  in  doses  of  thirty  grains.  They  are  supported  with 
more  difficulty  than  even  the  emetic  tartar.  I  prefer  to  them  the 
white  oxyd  of  antimony,  which  may  be  carried  to  the  extent  of 
four  or  five  drams  per  day,  but  without  being,  even  in  this  dose, 
of  very  decided  power. 

Regimen  in  Pneumonia. — In  the  acute  stage  of  severe  pneu- 
monia, the  patient  ought  to  be  debarred  from  every  kind  of  ali- 
ment except  sugar  and  the  mucilaginous  matters  which  enter  into 
the  composition  of  his  drinks.  As  soon,  however,  as  the  inflam- 
matory action  has  subsided,  he  must  be  allowed  some  slight  food, 
to  be  increased  as  the  appetite  returns.  In  general,  we  ought,  in 
all  diseases,  to  be  afraid  of  carrying  the  complete  inhibition  of 
food  beyond  a  few  days.  Many  physicians  of  the  present  day 
seem  to  have,  in  this  respect,  forgotten  the  wise  precepts  of  Hip- 
pocrates (Aph.  16.  et  seq.  sect,  i.)  who  lays  down  in  a  few 
aphorisms  all  that  can  be  truly  and  exactly  predicated  of  absti- 
nence. Some  even  seem  to  be  ignorant  that  a  sick  man  may  die  of 
starvation  as  well  as  a  healthy  one  ;  and  appear  to  have  no  idea 
that  the  symptoms  resulting  from  inanition  are,  in  a  great 
measure,  similar  to  those  of  the  various  stomach  affections,  which 
they  consider  as  gastritis.  The  great  and  most  frequent  evil  of 
extreme  abstinence  in  acute  diseases,  is  to  create  such  an  irrita- 
bility of  stomach,  as  renders  the  nourishing  of  the  patient,  after 
the  fever  has  subsided,  extremely  difficult,  and  thereby  occasions 
a  long  and  dangerous  convalescence.*  Too  great  heat,  produced 
by  too  much  covering  or  defective  ventilation,  is  extremely  pre- 
judicial. When  this  is  observed,  we  need  not  be  afraid  to  un- 
cover the  patient  for  a  few  minutes,  and  expose  him  to  a  cooler 
air.     Some  authors  have  recommended  bathing  in  this  disease. 

ical  aid,  a  clyster  every  other  day  excepted.  I  have  lately  seen  a  great  many 
cases  similar  to  the  above,  and  the  tartarized  antimony  has  invariably  produced 
the  same  effect." — Transl. 

*  It  is  possible,  no  doubt,  to  carry  the  best,  practice  to  an  injurious  extreme  ; 
and  we  may  unquestionably  starve  our  patients,  as  well  as  stimulate  them  into 
disease.  At  the  same  time,  I  am  convinced  by  every  day's  experience,  that  for 
one  instance  of  mischief  produced  by  too  great  abstinence  in  the  convalescence 
from  acute,  and  especially  inflammatory  diseases,  there  area  thousand  occasioned 
by  the  opposite  extreme  ;  and  I  would,  therefore,  earnestly  request  the  young  prac- 
titioner not  to  be  seduced  into  the  too  early  exhibition  of  nutritive  food  to  his 
•convalescents,  from  fetfrs  of  dangerous  debility,  or  any  other  cause.  What  Brou- 
sais  says  in  respect  of  bloodletting,  is  equally  applicable  to  abstinence,  and  I 
would  advise  the  student  to  treasure  the  great  pathological  truth  contained  in 
the  following  sentence,  as  containing  in  itself  more  real  practical  utility  than  is 
to  be  found  in  many  splendid  theories  "  Ce  ne  sont  point  les  pertes  de  sang  qui 
prolongent  les  convalescences;  ce  sont  les  points  d  irritation  qui  restent  dans 
les  visceres;  et  souvent  les  stimulants  et  les  pretendus  toniques  que  Ton  s'em- 
presse  de  prodiguer,  afin  de  reparer  les  forces  que  Ton  vient  d'enleve,  par  la 
saignee,  contribuent  a  entretenir  ces  foyers  chroniques  de  phlegmasie,  et  a  ren- 
dre  le  retablissement  plus  difficile."     (Ezamcn  dcs  Doct.  Med.  p.  503.;—  Transl. 


TREATMENT    OF    PNEUMONIA. 


277 


1  have  little  experience  of  this  mode  of  treatment,  wlijch  must  be 
very  inefficient  in  an  affection  like  tins. 

I  shall  conclude  this  chapter  with  a  case  of  pneumonia  ending 
in  resolution.  I  would  gladly  have  added  a  case  of  chronic  pneu- 
monia, but  the  history  of  the  most  remarkable  of  these  has  been 
lost. 

Case  XVI.  Disease  of  the  heart. — Double  pneumonia  (in  a 
state  of  resolution,)  with  partial  pleurisy.  A  man  twenty-two 
years  of  age,  who  had  suffered,  during  the  five  preceding  years, 
from  continual  dyspnoea  and  a  very  frequent  palpitation,  came 
into  the  hospital  on  the  29th  March,  1825.  He  gave  a  very  im- 
perfect account  of  his  complaints,  but  it  appeared  that  they 
supervened  to  an  acute  attack  of  fever  accompanied  by  bilious 
vomiting  and  pains  in  the  abdomen.  He  had  likewise  been  sub- 
ject, from  his  childhood,  to  frequent  fainting-fits,  which  some- 
times lasted,  according  to  his  account,  ten  or  twelve  hours ;  but 
these  attacks  had  ceased  about  the  age  of  puberty.  The  follow- 
ing was  the  state  of  his  symptoms  on  his  admission  :  very  con- 
siderable dyspnoea  ;  respiration  good  and  pure  anteriorly,  accom- 
panied by  an  obscure  mucous  rhonchus  posteriorly  ;  palpitations  ; 
action  of  the  heart  preternaturally  quick,  sensible  to  the  touch, 
yielding  on  the  right  (that  is,  under  the  lower  part  of  the  ster- 
num,) a  strong  impulse  and  a  very  considerble  &>und,  and  on 
the  left,  a  febler  impulse  but  louder  sound.  Diagnosis  :  hyper- 
trophy with  dilatation  of  the  heart,  particularly  on  the  right 
side;  pulmonary  catarrh.  (V.  S.  to  12  oz. ;  barley  water;  a 
scruple  of  digitalis  in  infusion,  with  a  mucilaginous  mixture  ; 
two  grains  of  acetate  of  lead.)  April  11.  Better.  Pulse  which 
had  been  rather  frequent,  more  natural ;  action  of  the  heart  sen- 
sibly less.  Pains  in  the  feet,  but  without  redness  or  swelling. 
Diagnosis  :  hypertrophy  of  the  right  ventrical  certainly  exists, 
but  it  is  not  sufficient  to  account  for  all  the  symptoms.  19th. 
Has  had  sore  throat  during  the  last  two  days,  for  which  twelve 
leeches  have  been  applied  with  relief.  There  is  now  a  slight 
pain  of  the  left  side  of  the  chest,  accompanied  by  a  pretty  strong 
sibilous  rhonchus,  intermixed  w;th  a  subcrepitous  mucous  one, 
at  the  roots  of  the  left  lung,  and  mucous  expectoration.  (Same 
med. :  emollient  gargle.)  25th.  Since  the  day  before  yesterday 
there  has  been  present  a  pretty  high  fever,  but  without  any  local 
pain  or  much  general  disturbance  of  functions.  The  impulse  of 
the  heart  is  much  stronger  than  before.  The  same  rhonchus  exists 
at  the  roots  of  the  left  lung.  ( V.  S.  to  eight  ounces.  Samq  med.*) 

*  The  existence  of  the  subcrepitous  rhonchus  at  the  roots  of  the  lungs  was  of 
itself  no  proof  of  inflammation,  as  it  is  common  in  subjects  with  disease  of  the 
heart.  Suspicion  was  now  excited  as  to  pulmonic  inflammation,  and  bloodletting 
was  prescribed  under  apprehension  of  incipient  pneumonia. — Author. 


278  TREATMENT  OF  PNEUMONIA. 

26th.  The* fever  continues  with  dyspnoea;  the  expectoration  u 
somewhat  viscid,  but  without  any  evident  pneumonic  character. 
There  is  no  pain  in   the  chest,  which  sounds  well  posteriorly. 
Respiration  pretty  good  on  the  right  back,  with  a  slight  subcre- 
pitous  rhonchus  at  the  root  of  the  lung, — weaker  on   the  left 
back  and  attended  by  a  distinct  crepitous  rhonchus  :  no  bron- 
chophony.    Diagnosis:  doable  pneumonia — slight  on  the  right 
side,  more  considerable  on  the  left.     ( V.  &.*  to  eight  ounces)  ; 
almond  emulsion  with  six  grains  of  emetic  tartar ;  mucilagi- 
nous mixture ;  broth,  (bouillon.)  f     27th.     Fever  and  dyspnopa 
somewhat  less :  repeated  vomiting  and  great  diarrhoea  ;  expecto- 
ration rusty,    mixed  with  large  air  bubbles.     The  chest  sounds 
somewhat  imperfectly  on  the  left  back,   and  there  is  a  subcrepi- 
tous  mixed  here  and    there  with  a  mucous  rhonchus   over    the 
whole  of   this  side :    and  there  is  also  a  subcrepitous  rhonchus 
in  different  points  over  the  whole  of  the  right  back,  and  even  on 
the  side :  Diagnosis  ;  lobular  pneumonia  of  the  posterior  parts 
of  both  lungs,  especially  the  left, — the  inflammation  having  ex- 
tended to  a  great  many  points.     (Six  grains  of  emetic  tartar 
in  an  emulsion,  ivith  an  ounce  'of  syrup  of  poppies ;  mucila- 
ginous mixture ;    abstinence  from  all   kinds  of  food  (diete) 
28th.  General  symptoms  the  same ;    no  vomiting  or  diarrhoea ; 
pulse  and    he%rt  still   preternaturally   strong ;    great    dyspnoea ; 
crepitous  or  subcrepitous  rhonchus  over  the  whole  left  side,  ex- 
cept on   the  upper  part  anteriorly,   and  also  over  the  whole  right 
back,  and  slightly  on  the  side  (same  med. ;  V.  S.  to  eight  ounces.) 
Diagnosis  :    The   inflamed  points   unite ;   the  pneumonia  ap- 
proaches the  surface. — 29th.     Fever  and  dyspnoea  still  great ; 
several  stools  but  no  vomiting;    expectoration  no  longer  rusty 
and  viscid,   but  white,   light,   yellow,   opaque,  and  almost  puri- 
form.     Chest  in  the  same  state,  except  that  the  crepitous   rhon- 
chus now  approximates  in  character  to  the  mucous.     The  hand 
placed  on  the  chest  perceives  the  vibration  of  the  sputa  within 
the  bronchi.     (Emetic  tartar  nine  grains,  syrup  of  poppies  two 
ounces.)     Diagnosis  :  the  expectoration  indicates  incipient  sup- 
puration, in  some  points  at  least. — 30th.  Fever  and  prostration  ; 
dyspnoea  increased ;    expectoration  more  difficult,  sputa  almost 
as  white  as  if  they  were  colored  with  milk  ;    sore    throat    and 
coryza  considerable ;   no  vomiting,   but  five    stools   within    the 
twenty-four  hours ;   respiration   every  where  pretty  good  on   the 
right  side,  only  with  a  crepitous  rhonchus  towards  the  roots  of 
• 

*  The  bleeding  was  repeated  on  account  of  the  disease  of  the  heart,  tlte 
presence  of  which  has  always  appeared  to  render  the  tartar  emetic  less  effica 
cious  in  pneumonia. — Author. 

t  An  extremely  weak  decoction  of  veal  or  chicken,  I  presume;  or  perhaps 
simply  of  herbs.  The  bouillon  da  veau  of  La  Charite  is  made  with  four  ounci  - 
of  veal  to  two  pounds  of  water. —  Transl. 


TREATMENT    OF    PNEUMONIA.  ^' ^ 

the  lung, — better  also  on  the  left,  but  still  accompanied  on  the 
back  by  a  crepitous  rhonchus  mingled  to-day  with  a  strong  mu- 
cous one  ;  slight  bronchophony  on  the  left  side.  (Same  med.  : 
V.  S.  to  eight  ounces.)  Diagnosis:  resolution  commences  on 
the  light,  and  also  on  the  left  side ;  but  in  the  latter,  there  is 
still  one  point  much  indurated,  near  the  surface  of  the  lung,  on 
the  side.     The  patient  died  the  following  day. 

Dissection  twenty-four  hours  after  Death. — There  was  some 
serous  effusion  under  the  membranes,  and  also  in  the  ventricles 
of  the  brain,  which  had  no  doubt  taken  place  during  the  last 
twenty-four  hours,  and  most  likely  in  a  great  measure  during 
the  few  last  moments  of  life.  The  right  lung  was  found  inti- 
mately adhering  to  the  costal  pleura,  by  short  and  very  firm  old 
cellular  attachments.  It  was  large,  somewhat  flabby,  and  al- 
though crepitous,  was  evidently  heavier,  and  more  compact  and 
elastic  than  natural.  Divided  longitudinally  through  its  whole 
mass,  it  was  found  of  a  yellowish  red  pale  color,  intermixed 
with  shades  of  very  light  ash-grey.  It  was  almost  as  dry  as  in 
the  sound  state,  but  yielded  on  pressure  a  slightly  yellowish  and 
somewhat  frothy  serosity.  Its  vessels  contained  little  blood.  At 
its  roots  and  lower  and  back  parts,  there  was  some  points  or 
nodules  of  a  redder  color,  more  dense  and  compact,  and  exud- 
ing a  bloody  serum.  The  nodules  were  for  the  most  part  con- 
fined to  single  lobules,  but  comprised  in  some  places  two  or 
three ;  they  were  not  accurately  circumscribed,  nor  uniformly 
indurated.  The  greater  number  were  harder  in  the  centre,  and 
exhibited  there  the  granular  texture  of  pneumonia  and  a  redness 
more  or  less  violet :  towards  their  exterior,  they  passed  insen- 
sibly through  a  shade  of  violet-grey  to  the  reddish  yellow  color 
of  the  natural  tissue.  The  portions  which  were  violet-grey  were 
injected  with  a  pretty  large  quantity  of  frothy  serum,  and  had 
nothing  of  the  granular  texture.  In  other  points  of  the  lungs 
a  good  many  nodules  existed  of  the  same  violet-grey  color 
throughout,  without  any  central  induration ;  these  were  of  the 
size  of  lentiles,  or  at  most  double  this  size,  and  occupied  the 
the  middle  of  the  lobules.*  The  left  lung  was  also  united  to  the 
pleura,  but  less  firmly  than  the  right.  On  the  anterior-inferior 
and  lateral  parts  there  was,  in  one  place,  about  the  size  of  the 
hand,  an  exudation  of  concrete  pus  and  serosity  like  whey, 
within  the  meshes  of  the  cellular  adhesions.f     The  jmlmonary 

*  These  characters  indicated  the  resolution  of  a  lobular  pneumonia,  which 
had  in  these  points,  reached  the  stage  of  hepatization.  The  weight  and  density 
of  the  parts  that  were  still  crepitous,  proved  that  these  had  been  engorged,  and 
were  not  yet  completely  in  a  state  of  resolution. — Author. 

\  This  is  an  example  of  partial  pleurisy  developed  amid  an  ancient  pleuritic 
cellular  tissue.  The  albuminous  exudation  in  this  part  was  the  cause  of  the 
bronchophony  observed  on  the  30th  April. — Author. 


280  TREATMENT  OF  PNEUMONIA. 

substance  presented  two  different  states  ;  anteriorly  and  supe- 
riorly, it  was  nearly  natural,  and  somewhat  more  elastic,  firmer, 
and  more  compact  than  the  sound  lung.*  Over  three-fourths  of 
the  posterior  portion,  it  was  still  more  dense  and  compact,  as 
elastic,  but  less  crepitous.  Over  this  space,  the  whole  pulmo- 
nary substance  was  of  a  pale  wine-lees  color,  or  slightly  violet, 
which  formed  a  marked  contrast  with  the  reddish  color  of  the 
anterior  parts.  It  exuded  on  pressure  a  small  quantity  of  yel- 
lowish and  somewhat  frothy  serum,  intermixed  with  small  gra- 
nules or  dots  of  a  puriform  fluid.  Some  pneumonic  nodules,  still 
red  and  granular  in  their  centre,  existed  at  the  roots  and  base  of 
the  lung  behind.  In  every  other  part  behind,  the  vesicular  tex- 
ture was  perceptible,  even  in  the  redder  and  denser  portions  dis 
seminated  through  it.  Both  lungs,  although  elastic  and  crepi- 
tous over  the  greater  part  of  them,  were  much  heavier  than  nat- 
ural. The  bronchial  membrane  was  every  where  red :  and  this 
color  extended,  though  in  a  less  degree,  to  the  trachea  and 
larynx,  which  were  otherwise  perfectly  sound.  The  heart  was 
equal  in  size  to  the  two  fists  of  the  individual.  The  left  ventricle 
was  large  and  its  walls  thin  ;  the  right  was  of  the  natural  dimen- 
sions, perhaps  somewhat  larger,  and  its  walls  were  almost  as 
thick  as  those  of  the  left.  The  right  auricle  was  covered  exter- 
nally by  a  great  many  small  cartilaginous  granulations,  of  the 
size  of  half  a  millet  or  hempseed,  and  situated  beneath  the  se- 
rous membrane.f 

*  A  mark  of  resolution  where  the  pneumonic  affection  had  probably  not 
reached  beyond  the  first  stage. — Jiuthor. 

t  LITERATURE  OF  PNEUMONIA. 

1565.  Galli  (A.)     Bascis  de  Peste,  Peripneumonia  pestilente,  <fcc.     Bnx.     fol. 

1618.  Tosii  (M.  A.)     De  nova  Peripneumoniam  curandi  ratione.      Ven.     4to. 

1636.  Baronio  ('Vine.)  De  Pleuripneum.  Flaminiam  infestante.  Lib.  ii.  Foroliv 
4to. 

1664.  Diemcrbroeck  (J.  de)  Disputationum  Pract.  P.  i.  ii.  de  morbis  capitis  et 
thoracis.     Utrecht.     12mo. 

1683.  Bellini  (Laur.)  De  urinis,  de  Morbis  capitis,  et  pectoris,  &c.  Bologna.  4to 

1739.  Huxham  (J.,  M.D.)   Essay  on  Fevers,  on  Peripncumonic,  &c.  Loud.  8vo. 

1742.  Tennent  (J.)  Epist.  to  Dr.  Mead  on  the  Epid.  Diseases  of  Virginia,  par- 
ticularly Pleurisy  and  Peripneumony.     Edin.     12mo. 

1759.  Bouillet(J.  H.  N.)  Mem.  sur  les  pleuro-pneumon.  epidemiques.  Beziercs. 

4to. 

1760.  Paul  (M.)    Traite  de  la  peripneumonie  (Transl.  from  Boerh.)  Par.  12mo. 
1775.  Bellini  (Horat.)     De  peripneumonia  in  vomicam  versa.     Rom.     8vo. 
1777.  Romain   (M.)   Essai   sur  la   maniere   de  traiter   les    peripneum.  blieuses 

Metz.     8vo. 
1777.  Loeber    (L.)     Von    der    lungenenzundung     eines    100-jahrigen    greises 

Dresd.     8vo. 
1779.  Musgrave    (S.,   M.D.)     Gulstonion   Lect.    (2nd   on   Pleur     and   Pripn.) 

Lond.     8vo. 
1782.  Longrois  (J.  de,  M.D.)  De  la  Pulmonie,  de  scs  symptoms,  Arc.    Par    3vo. 
1788    Fiorani  (A  )     Saggio  sopra  la  peripneumonia      Pisa.     4to. 


PHTHISIS    PULMONALIS.  281 

CHAPTER  VIT. 

OF    ACCIDENTAL    PRODUCTIONS    DEVELOPED    IN    THE    LUNGS. 

Under  the  term  accidental  productions,*  I  comprehend  every 
substance  foreign  to  the  natural  organization  of  a  part,  which  any 

1789.  Saalmann,  (F.,  M.D.)     Descriptio  Pleuritids,  Peripneumoniae,  &c.  Mon. 

W.     8vo. 

1790.  Sachtleben  (D.   W.)     Bemerk.  ueber   die   heilung   der  brustenzundung. 

Goett. 
1793.  Scherer  (J.  A.)     Ueber  das  einathmen  der  lebensluft  in  langwierigen 

brustenzundung.      Wein.  8vo. 
1796.  Kreysig  (F.  L.)      Comment,  de  peripnenmonia  nervosa.     Lips.  8vo. 
1802.  Horn  (E.)  Ueber  die  erkenntniss,  &c.  der  Pneumonic     Frankf.    8vo. 

1802.  Hcun.  (C.  G.)     De  Pneumoniae  tbeoria,  &c.     Lips.     4to. 

1803.  Conradi  (J.  W.  H.)     Pneuinonie  und  Pleuritis  in  nosologischer  und  the- 

rapeutischer  liinsicht.     Marb.     8vo. 
1803.  Racine  (C.)     Recherches  sur  la  pleurisic  et  sur  la  peripneumonie  latente 

chronique.     Par.     8vo. 
1815.  Pacini  (L.)     D'una  suppurazione  pulmonale  relazione.     Lucca.     8vo. 

1815.  Valentin.  (L.)     Memoires  sur  les  fluxions  de  poilrine.     Nancy.    8vo. 

1816.  Mann  (J.)     Med.  Sketches  of  the  Campaigns  of  1812-13-14,  with  obs. 

on  peripneumonia  notha,  &c,     Dedkam.     (Amer.)  8vo. 
1820.  Pinel  and   Bricheteau.     Diet.  des.  Sc.  Med.  (Art.  Pneumonic,)  t.  43.  Par. 

8vo. 
1827.  Chomel.     Diet,  de  Med.  (Art.  Pneumonic,)  t.  17.     Par.     8vo. 
1834.  Williams.  Cyclopaedia  of  Pract.  Med.  (Art.  Pneumonia)  vol.  iii.  Lond.  8vo. 

Transl. 
*  This  phrase  appears  to  me  the  most  appropriate  one  that  can  be  employed 
in  the  present  state  of  the  science,  to  designate  the  change  which  takes  place  in 
the  nutritive  process  in  the  tissues  which  are  the  seat  of  accidental  productions. 
None  of  them  can  be  ascribed  solely  to  a  mere  super-activity  of  nutrition,  or  to 
a  diminution  of  this  activity  ;  and  they  are  very  erroneously  in  certain  nosolo- 
gical classifications,  comprised  under  the  head  of  a  large  class  of  diseases,  called 
secretory  irritations.  I  have  for  a  long  time  been  endeavoring  to  show,  espe- 
cially in  my  Pathological  Anatomy,  that  in  referring  the  cause  of  these  acciden- 
tal productions  to  an  irritation,  no  explanation  is  given  of  their  development; 
still  less  of  their  several  peculiar  characteristics.  In  the  greater  number  of 
cases,  this  irritation  can  be  admitted  only  by  mere  inference,  and  this  may  lead 
to  serious  errors.  There  is,  in  fact,  no  proof  in  a  great  many  cases,  that  in  the 
quarter  where  an  accidental  production  is  developed,  there  is  at  first  any  aug- 
mentation of  the  vital  powers,  any  uncommon  activity  of  the  nutritive  function, 
or  an  unusual  afflux  of  blood.  Yet  there  are  other  cases  in  which  the  diverse 
phenomena  of  inflammation,  among  which  we  must  place  irritation,  are  mani- 
fest, where  an  accidental  production  is  forming.  In  these  instances,  inflam- 
mation may  justly  be  regarded  as  the  agent  by  which  the  production  is  caused  ; 
but  this  alone  cannot  explain  its  development ;  its  operation  is  limited  to  that 
of  a  mere  agent  of  impulsion.  It  brings  on  a  derangement  in  the  nutritive 
process  ;  predisposition  does  the  rest!  The  nutrition  might  have  been  deranged 
and  perverted,  and  thus  have  given  rise  to  an  accidental  production  without  any 
antecedent  inflammation,  active  congestion  or  irritative  process  whatever.  If 
we  imagine  we  have  sufficiently  explained  the  cause  in  ascribing  it  to  irritation, 
we  have  no  further  researches  to  make,  and  the  science  is  perfect.  If  on  the 
contrary,  while  we  admit  that  irritation  may  sometimes  intervene  as  one  of 
the  agents  in  the  development  of  accidental  productions,  we  consider  it  a  cause 
neither  necessary  nor  constant  ;  if  we  are  convinced  that  even  in  these  cases,  it 
has  only  a  secondary  influence,  and  that  it  never  acts  a  higher  part  than  that  of 

36 


262  PHTHISIS     PULMONALIS. 

aberration  in  the  nutrition  may  develope  in  our  organs.  These 
various  substances  may  be  divided  into  two  classes,  according  as 
they  are,  or  are  not  analogous  to  some  of  the  natural  textures  of 
the  body.  Under  this  first  head  we  may  range  all  productions 
of  a  cellular,  serous,  mucous,  fibrous,  bony,  &c.  character; 
under  the  second,  all  the  varieties  of  cancer.*     In  the  following 

an 'occasional  cause — then  the  field  of  research  opens  anew,  and  we  examine 
those  circumstances,  physical  or  chemical,  which  by  deranging  the  mode  in 
which  the  materials  of  the  different  tissues  are  separated  from  the  blood,  pro- 
duce cartilage  instead  of  fibrous  tissue,  or  tubercle  instead  of  cellular  tissue. 
The  science  of  therapeutics  in  its  endeavor  to  prevent  the  formation  of  acci- 
dental productions,  or  to  retard  their  progress,  has  a  course  to  pursue  quite 
different  from  that  of  employing  a  debjlitating  process  which  is  directed  only 
against  inflammation,  and  does  not  reach  the  true  causes  of  these  productions. 
It  must  not  be  forgotten,  that  when  the  production  is  once  developed,  it  seldom 
happens  that  sooner  or  later  it  does  not  bring  around  it  an  inflammatory  opera- 
tion which  demands  serious  attention,  both  in  the  interpretation  of  the  symp- 
toms and  in  the  application  of  remedies  ;  and  even  in  this  case,  in  checking  the 
inflammatory  operation,  which  may  be  compared  to  that  occasioned  by  the  intro- 
duction of  a  foreign  substance  into  a  living  part  of  the  body,  it  is  only  with 
great  reserve  that  antiphlogistic  treatment  should  be  employed. — Jindral. 

*  Accidental  productions  developed  within  the  living  parts  of  the  body,  may 
consist  of  simple  transformation  of  the  regular  tissues,  one  within  the  other  ; 
these  transformations  are  subjected  to  certain  laws,  which  may  be  reduced  to 
form  in  the  following  manner  : — 

1.  All  the  tissues  of  the  normal  state  may  accidentally  and  under  morbid  in- 
fluences, be  produced  at  the  expense  of  the  cellular  tissues.  This  last  becomes 
impregnated  in  some  way  with  the  materials  of  which  they  arc  constituted,  and 
is  thus  replaced  by  them.  Yet  there  are  two  tissues,  the  nervous  and  the  muscu- 
lar, which  we  never  see  thus  produced  like  the  rest,  by  the  transformation  of 
cellular  tissue  :  they  merely  repair  themselves    when  they  have  been  destroyed. 

2.  The  nature  of  the  transformation  of  the  cellular  tissue  is  rigorously  deter- 
mined in  certain  cases,  by  the  nature  of  the  functions  which  it  may  be  accidentally 
called  upon  to  perform.  Thus,  where  an  unaccustomed  friction  is  exercised,  it 
becomes  serous  tissue  ;  where  there  is  an  accidental  necessity  of  an  elastic  ac- 
tion, it  becomes  cartilaginous  tissue  ;  where  there  is  a  necessity  of  a  protection 
for  living  matter  against  a  foreign  body,  it  becomes  tegumentary  tissue  more  or 
less  perfect,  as  may  be  seen  in  the  coats  of  many  fistulous  passages,  &c. 

3.  Besides  the  cellular,  the  only  tissues  susceptible  of  transformation  are  those 
which,  during  embryotic  or  mere  animal  life,  present  an  aptitude  for  transforma- 
tion into  other  tissues. 

4.  The  accidental  transformations  which  these  tissues  may  experience  are  of 
the  same  nature  with  the  normal  transformations  to  which  they  are  liable  either 
in  the  human  fcetus,  or  in  full  grown  animals.  Thus  cartilage  may  turn  to  bono, 
but  it  never  becomes  mucous  tissue  :  mucous  tissue  may  turn  to  cutaneous  tissue, 
and  vice  versa  :  muscular  tissue  may  turn  to  fibrous  tissue,  but  here  the  transfor- 
mations stop,  being  more  restricted  than  those  of  the  cellular  tissue. 

5.  Every  tissue  which  becomes  atrophied,  tends  toward  a  common  transfor- 
mation ;  it  returns  to  the  condition  of  cellular  tissue.  Thus,  in  the  adult  this 
tissue  is  found  in  the  place  of  the  thymus  gland,  which  in  the  foetus  occupies  the 
anterior  mediastinum  ;  likewise  in  some  cases  of  accidental  atrophy  of  the  gall 
bladder,  nothing  was  found  in  the  place  commonly  occupied  by  this  organ  but 
masses  of  cellular  tissue,  &x.  (See  my  Pathological  Anatomy.) 

Other  accidental  productions,  quite  different  from  the  preceding,  are  formed 
altogether  in  the  midst  of  the  tissues  which  preserve  their  normal  organization, 
and  which  in  the  first  stages  at  least  of  their  existence,  are  merely  thrust  back 
by  them  :  but  at  a  later  period,  being  affected  by  the  presence  of  these  productions 
as  by  a  foreign  body,  they  decay  and  disappear,  either  in  consequence  of  simple 
atrophy  or  by  inflammation ;  this  is  an  example  of  the  secondary  inflammation 
mentioned  in  the  preceding  note. 


PHTHISIS    PULMONALIS.  283 

chapters  I  shall  only  treat  of  those  accidental  productions  which 
I  have  myself  had  occasion  to  observe  in  the  lungs.  These  are : 
1.  cysts,  properly  so  called  ;  2.  cysts,  containing  vesicular  worms, 
or  hydatids ;  3.  substances  of  a  fibrous,  cartilaginous,  bony  or 
chalky  nature ;  4.  tubercles ;  5.  that  species  of  cancer  denomi- 
nated encephaloid  or  cerebriform ;  and  6.  that  other  variety  of 
cancer  which  I  have  termed  melanosis.  I  will  treat  of  tubercles 
in  the  first  place,  because  what  I  shall  have  to  notice  respecting 
this  variety  of  accidental  production,  will  tend  to  illustrate  the 
history  of  other  varieties. 

The  pi  ogress  of  pathological  anatomy  has  successfully  demon- 
strated that  phthisis  pulmonalis  is  owing  to  the  development  in 
the  lungs,  of  a  particular  species  of  accidental  production,  to 
which  modern  anatomists  have  restricted  the  name  of  tubercle,  a 
term  formerly  applied  to  every  kind  of  preternatural  tumor  or 
protuberance.  This,  I  think,  is  the  only  kind  of  phthisis  which 
we  should  admit,  unless,  indeed,  it  were  the  phthisis  nervosa* 

Among  these  accidental  productions,  some,  which  are  the  simple  result  of  a 
vitiated  secretion,  exhibit  no  character  of  organization;  such  are  the  deposits  of 
saline,  fatty  or  coloring  matter,  &c,  of  which  all  the  organs  may  become  the 
seat.  Another  accidental  production,  the  tubercle,  offers  no  more  apparent 
marks  of  organization  than  the  preceding ;  yet  it  should  be  distinguished  from 
them  by  the  constancy  of  its  shape,  its  regularity  of  development  and  the  uni- 
formity of  the  changes  which  take  place  in  it, — changes  which  are  remarkable-, 
and  mark  out  in  its  existence  a  certain  number  of  determined  phases  which  it 
is  obliged  to  pass  through  in  order  to  attain  its  period  of  destruction. 

The  organization  is  more  evident  in  other  accidental  productions,  when  it  be- 
comes manifest  by  the  existence  of  a  texture,  as  in  schirrus,  or  by  the  presence 
of  a  circulation  as  in  encephaloid  tumors. 

Finally,  other  productions  exhibit  not  only  the  marks  of  an  organization  more 
or  less  advanced,  but  they  constitute  real  beings,  which  in  the,  parts  in  which 
they  are  developed,  enjoy  their  own  peculiar  and  independent  life:  such  are 
the  entozoa. 

There  are  certain  pathological  conditions  which  a  superficial  observation  may 
lead  us  erroneously  to  ascribe  to  accidental  productions.  Thus  the  schirrus  of 
the  liver  has  been  considered  by  Laennec  himself,  wrongly  in  my  opinion,  as 
the  result  of  an  accidental  production  of  a  peculiar  nature  in  the  substance  of 
this  organ.  In  the  same  manner  the  name  of  tubercle  has  often  been  given  to 
follicles  in  a  state  of  hypertrophy  and  which  are  more  distinct  than  common. 
I  think  I  have  also  proved  that  in  many  cases  of  chronic  gastritis,  the  several 
tissues  of  the  stomach  have  in  consequence  of  hypertrophy  or  atrophy  so 
changed  their  appearance,  that  the  alterations  have  been  described  as  cancerous 
affections  of  the  stomach. — Andral. 

*  In  supposing  the  existence  of  a  malady  in  which,  without  any  perceptible 
organic  lesion,  the  patient,  in  consequence  of  severe  nervous  excitement,  reaches 
that  degree  of  exhaustion  and  emaciation  which  determines  tuberculous  affec- 
tion of  the  lungs,  such  a  malady  can  resemble  pulmonary  phthisis  only  by  the 
debility  and  emaciation  which  it  causes.  If  we  incline  to  call  it  nervous  phthisis 
we  must  also  give  this  name  to  all  those  morbid  states  in  which,  by  the  influence' 
of  many  diverse  causes,  a  consumption  may  supervene.  In  this  way  the  term 
phthisis  may  be  applied  to  all  chronic  disorders,  whatever  be  their  nature  or 
seat ;  for  all  of  them  have  the  common  effect  of  producing  debility  and  emacia- 
tion. In  a  great  many  more  of  these  maladies,  we  observe  these  symptoms  as  a 
sort  of  prelude  to  them,  and  long  before  any  local  signs,  however  obscure  or 
imperfect,  can  direct  us  to  the  precise  point  where  they  are  seated.  The  an- 
cients thus  admitted   their   hepatic,  splenetic  and   intestinal   phthisis,  &c.  •  and 


284  PHTHISIS    PULMONALIS. 

and  the  chronic  catarrh  stimulating  tuberculous  phthisis.  The 
varieties  termed  scorbutic,  venereal,  &c.  are  all  essentially  tuber- 
culous, differing  only  from  the  common  species  by  the  cause  (per- 
haps gratuitous)  to  which  the  development  of  the  tubercles  is 
attributed.*  In  respect  of  the  species  described  by  Bayle  under 
the  name  of  granular,  ulcerous,  calculous,  cancerous,  and  with 
melanosis,  I  may  here  remark,  that  the  first  is  a  mere  variety  of 
the  tuberculous ;  the  second  is  the  'partial  gangrene  of  the  lungs, 
formerly  described ;  and  the'  three  others  are  affections  which 
have  nothing  in  common  with  the  tuberculous  phthisis  except 
that  they  have  their  seat  in  the  same  organ. 

The  progress  of  the  development  of  tubercles  has-been  de- 
scribed by  Bayle  in  a  much  more  exact  and  complete  manner 
than  had  been  done  before  him.f  Nevertheless,  from  having 
been  enabled  by  more  recent  observations  to  rectify  or  extend 
several  of  his,  I  deem  it  essential  to  the  comprehension  of  what 
I  shall  have  to  state,  to  give,  in  this  place,*  an  abridged  exposi- 
tion of  the  characters  and  mode  of  development  of  tubercles,  for 
which  I  might  otherwise  have  contented  myself  by  a  reference  to 
his  work. 

Sect.  I.  Anatomical  history  of  tubercles. 

The  matter  of  tubercles  may  be  developed  in  the  lungs, 
or  other  organs,  under  two  principal  forms, — that  of  insu- 
lated bodies  and  infiltration.  Each  of  these  presents  several 
varieties,  chiefly  referable  to  the  different  degrees  of  develop- 
ment. The  insulated  tubercles  present  four  chief  varieties 
which  I  shall  denominate  miliary,  crude,  granular,  and  encysted. 

in  the  same  sense  the  expression  laryngial  phthisis,  is  contained  in  our  medical 
phraseology. — Andral. 

*  Many  authors  have  used  the  expression  venereal  phthisis  to  signify  a  very 
different  thing  from  pulmonary  phthisis  :  they  have  given  this  name  to  a  partic- 
ular cachexy  caused  by  the  venereal  affection  when  of  long  standing  or  neglected. 
This  is  a  species  of  consumption,  the  existence  of  which  cannot  be  denied,  and 
the  cause  of  which  is  not  the  suffering  of  a  particular  organ,  but  the  gradual 
infection  of  the  blood  by  the  introduction  of  a  foreign  substance  into  it,  which 
acts  upon  the  organ  and  subsequently  upon  the  whole  system,  in  the  manner  of 
a  poison.  There  is  no  doubt  that  during  this  cachexy,  pulmonary  tubercles  may 
arise,  the  more,  because  every  debilitating  influence  is  at  least  a  predisposing 
cause  of  tuberculous  matter.  In  this  manner  syphilitic  consumption  may  con- 
duce to  the  development  of  pulmonary  phthisis.  Cases  of  this  last  affection 
supervening  in  individuals  already  infected  with  the  venereal  taint,  have  been 
denominated  by  some  writers,  and  by  Portal  in  particular,  venereal  phthisis. 
They  consider  the  venereal  virus  in  these  cases,  to  be  the  cause  of  the  devel- 
opment of  the  pulmonary  affection.  In  my  opinion  they  are  in  error  ;  it  is  not 
the  virus  which  directly  produces  the  tubercles  in  the  lungs,  but  the  debility  of 
the  whole  system  caused  by  the  presence  of  particular  lesions.  Further,  it  must 
not  be  forgotten  that  in  many  cases  the  first  indications  of  pulmonary  phthisis  ap- 
pear after  the  administration  in  undue  quantity  of  mercurial  preparations. — Andral. 

\  Recherches  sur  la  Phthisie  pulmonale.     Paris,  1810. 


PHTHISIS    PULMONALIS. 


285 


Tuberculous  infiltration  offers  in  like  manner  three  varieties, 
which  I  term  the  irregular,  the  grey  and  the  yellow.  Whatever 
be  the  form  under  which  the  tuberculous  matter  is  developed,  it 
presents  at  first  the  appearance  of  a  grey  semi-transparent  sub- 
stance, which  gradually  becomes  yellow,  opaque,  and  very  dense. 
Afterwards  it  softens,  and  gradually  acquires  a  fluidity  nearly 
equal  to  that  of.  pus ;  it  being  then  expelled  through  the  bron- 
chi, cavities  are  left,  vulgarly  known  by  the  name  of  ulcers  of 
the  lungs,  but  which  I  shall  designate  tuberculous  excavations* 
I  shall  describe  the  different  varieties  in  succession. 

■•  In  Laennec's  observations  on  tubercle  in  this  chapter,  he  has  not  taken  up 
the  important  and  delicate  question  :— Is  tubercle  simply  an  inorganic  substance 
deposited  in  the  tissue  like  pus  or  calculous  concretion  ?  or,  is  it,  on  the  contra- 
ry a  substance  with  organization  and  life,  destined  to  pass  through  certain 
phases  of  development,  and  finally  to  decay  and  die  ?  These  questions  have 
long  divided  the  opinions  of  pathologists. 

The  opinion  which  regards  tubercle  as  an  Fnorganic  production  separated  from 
the  blood  like  secreted  matter,  is  of  a  date  much  anterior  to  the  present  day  ; 
it  is  announced  in  form  by  Morton,  in  his  physiology,  thus  :— 

The  first  cause  of  pulmonary  phthisis  must  be  looked  for  in  the  corruption  of 
the  blood  from  divers  causes,  which  Morton  examines  attentively,  observing,— 
"  In  consequence  of  this  corruption,  there  separates  from  the  mass  of  the  blood 
a  bad  matter,  which,  being  secreted  particularly  in  the  tissue  of  the  lungs, 
fills  (infarcit)  this  organ  in  every  part,  irritates  and  finally  brings  on  ulceration.. 
Before  the  ulcer  forms,  small,  hard  substances  are  found  in  the  lungs,  resembling 
the  tumor  called  by  Galen  crude  tubercle,  an  appropriate  name." 

Morton  adds,  "  qua  tubercula  sine  crudos  et  granulosos  tumores  saepe  in 
phthisicorum  cadaveribus  deprehendi  cum  cetera  pulmonum  partes  apostematibus 
et  exulcerationibus  essent  obsita."  Does  not  this  phrase  describe  as  exactly  as 
possible  the  state  in  which  we  find  the  lungs  of  those^vho  die  of  consumption 
at  an  advanced  period  of  the  malady  ?  Besides  this,  Morton  divides  phthisis  into 
chronic  and  acute,  according  as  the  tubercles  compared  by  him  to  the  scro- 
fulous tumors  of  the  other  parts  of  the  body,  remain  long  in  their  crude  state,  or 
come  speedily  to  suppuration.  Consequently,  it  is  not  in  modern  works  alone 
that  we  are  to  search  for  just  notions- upon  the  pathological  anatomy  of  pulmo- 
nary phthisis.  There  is,  besides  in  the  ancient  passage  above  quoted,  a  capital 
idea  which  several  cotemporary  authors  have  justly  repeated,  namely,  that  of  con- 
necting the  production  of  tuberculous  matter  with  the  state  of  the  blood,  deriv- 
ing it  from  this  state,  and  consequently  referring  it  to  a  general  affection  of  the 
syitem  of  which  the  pulmonary  lesion  is  a  mere  fraction,  or,  in  other  words, 
an  effect.  I  shall  have  occasion  in  a  subsequent  note,  to  touch  again  upon  this 
point   so  immediately  connected  with  the  treatment  of  phthisis. 

After  all  in  adopting  the  opinion  that  tubercle  is  an  inorganic  production  with- 
out life  we  must  look  beyond  the  tubercle  itself  for  the  cause  of  the  different 
changes  to  which  it  is  subjected  from  its  first  formation  which  can  be  carried 
on  only  by  the  juxtaposition  of  new  molecules,  and  not  by  intus-susception. 
The  same  may  be  said  of  the  cause  of  its  softening  and  its  destruction.  I  have 
stated  in  my  Clinique  and  Anatomic  Pathologique  the  grounds  on  winch  I  have 
founded  my  belief  that  tubercle  is  the  product  of  a  morbid  secretion,  in  which 
we  are  not  to  look  for  organization  or  any  act  of  life.  I  have  also  explained  the 
softening  of  the  tubercle  by  an  inflammation  which  brings  on  the  suppuration  of 
the  tubercle,  and  finally  eliminates  the  tuberculous  matter.  Laennec,  on  the  con- 
trary, maintained  that  "the  tubercle  is  a  real  living  tissue,  and  contains  within  it- 
self the  causes  of  the  changes  it  undergoes,  and  that  in  softening  it  dies  like  any 
other  living  thing.  But  Laennec  in  admitting  the  vitality  of  the  tubercle,  has  not 
touched  the  question  how  far  it  would  be  possible  to  demonstrate  an  organization, 
and  for  my  part,  I  long  ago,  by  a  careful  examination  or  tubercles,  came  to  a 
negative  conclusion  on  this  point.     We  do  not  in  fact,  discover  in  the  tubercle, 


286  PHTHISIS    PULMONALIS. 

Miliary  tubercles. — This  is  the  most  common  form  under 
which  the  tuberculous  matter  appears  in  the  lungs.     The  tuber- 

either  canals,  aroolce.  fibres  or  layers;  it  seems  to  be  a  homogeneous  mass,  like 
the  amorphous  concretions  of  different  natures,  which  result  from  a  sort  of  pre- 
cipitation of  the  solidifiable  elements  of  our  liquids.  At  a  recent  date,  how- 
ever, Dr.  Kuhn  having  submitted  tubercles  in  their  first  stage  to  microscopic 
examination,  declares  that  he  discovered  in  them  a  texture  altogether  peculiar  : 
this  writer  informs  us  that  tubercles  under  the  microscope  have  a  mamelonated 
aspect,  and  appear  to  consist  of  an  assemblage  of  irregular  yellowish  corpuscles 
connected  together  by  filaments  of  extreme  tenuity.  This  would  be  a  real 
tissue  which  Kuhn  proposes  to  call  tuberous  tissue.  It  has  for  its  base,  he  in- 
forms us,  very  delicate  threads  of  a  gelatinous  appearance,  ramified  or  anasto- 
mosed together  and  contained  in  a  sort  of  muco-membranous  envelop.  Around 
these  threads  and  in  the  mucous  envelop,  are  spread  a  vast  number  of  albumi- 
nous globules,  which  appear  to  detach  themselves  from,  or  be  the  product  of,  the 
threads  in  question.  These  threads  furnished  with  their  envelop  establish  a 
communication  among  the  different  corpuscles  which  compose  the  tuberous 
tissue.  In  these  corpuscles  they  produce  numerous  ramifications  round  which 
also  are  found  great  numbers  of  globules.  In  order  to  perceive  the  whole  of 
this  arrangement,  which  resembles  that  of  certain  formations  of  mould  in 
clusters  or  strings,  Dr.  Kuhn  shows  that  it  is  only  necessary  to  magnify  it  ten  or 
fifteen  times  the  diameter  of  the  tubercle.  When  examined  as  near  the  time 
of  its  first  formation  as  possible,  it  is  found,  continues  Dr.  Kuhn,  that  these 
globules  float  in  a  clear  mucus  more  or  less  abundant;  at  a  later  period  the 
mucus  is  absorbed,  the  globules  collect  and  form  a  tuberculous  mass  in  a  state 
of  crudity.  Afterwards  is  it  the  exhalation  of  a  new  liquid  which  separates  the 
globules  and  thus  brings  about  the  softening  of  the  tubercles? 

At  the  period  when  the  sputa  of  consumptive  persons  have  not  yet  become 
purulent,  and  when  by  the  naked  eye  they  could  not  be  distinguished  from 
those  of  bronchitis,  Dr.  Kuhn  affirms  that  he  has  seen  with  the  microscope,  the 
same  tuberous  tissue  which  is  described  above.  This  would  be  doubtless  a  most 
valuable  discovery  for  diagnosis,  and  which  would  remove  many  uncertainties 
in  relation  to  the  comm^icement  of  pulmonary  phthisis. 

No  one  yet  as  far  as  I  know,  has  undertaken  to  verify  by  new  researches,  the 
correctness  of  Dr.  Kuhn's  statement. 

It  was  incumbent  on  me  to  announce  them  without  pretending  in  any  way  to 
judge  of  their  value.  The  theoretical  and  practical  conclusions  to  which  they 
may  lead,  render  it  well  worth  the  while  to  observe  how  far  they  are  confirmed 
by  facts. 

The  seat  of  tubercles  in  the  lungs  has  given  rise  to  no  less  diversity  of  opin- 
ion than  their  peculiar  texture.  It  has  been  said  that  these  bodies  are  devel- 
oped in  the  lymphatic  vessels  contained  in  the  lungs  :  it  has  also  been  affirmed 
that  they  are  seated  in  the  lymphatic  glands  of  the  lungs,  and  that  they  are  no- 
thing less  than  these  lymphatic  glands  degenerated.  These  are  obsolete  notions, 
not  worth  refuting.  Still  I  will  remark  that  the  most  exact  anatomy  cannot 
discover  in  the  normal  state,  any  lymphatic  glands  in  the  interior  of  the  lungs  ; 
on  the  other  hand,  I  have  found  sometimes,  the  lymphatic  vessels  which  lie  on 
the  surface,  or  in  the  interior  of  the  lungs,  either  filled  with  pus  or  distended 
by  a  concrete  substance  resembling  cancerous  or  tuberculous  matter;  yet  in  such 
cases,  the  lungs  contained  nothing  resembling  real  tubercles.  For  farther  de- 
tails of  these  cases  see  my  Clinique  Medicate  and  Annt.  Path. 

Others  have  placed  the  seat  of  the  tubercle  in  the  air  vesicles  themselves  ;  they 
have  imagined  that  tubercle  is  nothing  but  a  morbid  matter,  a  sort  of  concrete 
pus  secreted  in  the  interior  of  these  vesicles.  Dr.  Carswell  of  London,  has  re- 
cently adopted  this  idea,  in  his  work  on  pathological  anatomy  i  according  to 
him,  the  gray  granulation  which  so  often  precedes  the  tubercle,  is  nothing  but  a 
matter  secreted  in  the  interior  of  the  vesicles,  and  the  subsequent  softening  of 
the  tubercle  is  occasioned  by  the  deposition  around  the  concreted  matter,  of  a 
new  and  more  liquid  matter,  which  separates  and  dissolves  the  molecules  of  the 
first  deposited  matter.  Such  an  opinion  appears  to  me  untenable  ;  because  the 
tubercles   in   fact,  may  arise  indifferently  in  all   the  organs,  and    they  always 


PHTHISIS    PULMONALIS. 


287 


cles  in  this  variety  resemble,  small  grains ;  they  are  of  a  grey 
color,  and  semi-transparent,  sometimes  even  transparent  and 
colorless,  and  of  a  consistence  somewhat  less  than  that  of  carti- 
lage. Their  size  varies  from  that  of  a  millet  to  that  of  a  hemp- 
seed.  Their  shape  roundish  at  first  sight,  is  found  on  inspec- 
tion, to  be  less  regular  when  examined  closely  and  with  a  lens ; 
they  sometimes  even  appear  somewhat  angular.  They  adhere 
intimately  to  the  pulmonary  substance,  insomuch  that  they  can- 
not be  detached  without  bringing  with  them  some  portions  of  it. 
They  grow  by  intus-susception,  and  thus  become  united  in 
groups.  Before  this  union,  however,  a  small  yellowish  opaque 
speck  appears  in  the  centre  of  each  tubercle  ;•  this  speck  gra- 
dually enlarges  and  finally  involves  the  whole  tubercle.  Very 
frequently  the  tubercles  coalesce  before  their  whole  substance 
undergoes  the  change  just  mentioned;  and  in  this  case,  when 
we  divide  one  of  the  masses  formed  by  the  union  of  several,  we 
can  regularly  recognise  the  small  yellow  points  indicating  the 
centres  of  the  respective  tubercles,  and  the  zone  of  unchanged 
grey  matter  surrounding  these.  After  a  certain  time,  the  con- 
version of  the  whole  into  this  yellow  matter  is  completed,  and 
the  group  then  constitutes  only  a  single  homogeneous  mass  of  a 
whitish  yellow  color,  and  of  a  texture  somewhat  less  compact 
and  moister  than  that  of  cartilage :  it  is  then  said  to  constitute 
the  yellow  crude  tubercle  or  simply  the  crude  tubercle.  When 
the  miliary  tubercles  are  a  little  distant  from  each  other,  they 
frequently  reach  this  stage  without  coalescing,  and  while  they 
are  still  only  of  the  size  of  millet  seed.  When  the  tubercles  are 
very  few  in  number,  for   example,  a  hundred  only  in  each  lung, 

originate  in  the  intimate  parts  of  their  texture  :  it  does  not  appear  why  the  air 
vesicles  of  the  lungs  should  be  regarded  as  their  seat. 

It  seems  much  nearer  the  truth  to  suppose  that  wherever  the  tubercle  arises, 
it  is  developed  in  the  texture  itself  of  the  different  organs,  particularly  in  the 
cellulo-vascular  tissue,  which,  to  use  the  words  of  Bichat,  is  a  common  ground 
for  the  deposition  both  of  the  ordinary  materials  of  the  normal  secretions  and 
nutritions,  and  the  morbid  elements  of  the  anormal.  It  would  be  very  strange 
if,  while  every  where  else  the  tuberculous  matter  originates  in  the  inner  recesses 
of  the  organic  texture,  it  should  be  different  in  the  lungs,  and  that  there  alone, 
contrary  to  what  is  known  of  any  other  part,  it  should  be  nothing  but  the  result 
of  a  vitiated  secretion  of  the  membrane  which  lines  the  ultimate  extremities  of 
the  bronchi.  Some  instances  have  indeed  been  cited  of  tuberculous  matter  found 
in  cavities  lined  by  the  mucous  membrane ;  it  is  said  to  have  been  found  in  the 
ureters  and  in  the  Fallopian  tubes.  I  have  myself  quoted  a  case  where  I  found 
in  a  horse  a  large  bronchus  full  of  a  cheesy  matter  like  tubercle.  Such  cases 
are  however,  rare,  and  should  undergo  a  re-examination  before  they  are  defi- 
nitely admitted.  Who  indeed,  can  be  confident  of  his  correctness,  when  in 
opposition  to  an  opinion  resting  upon  a  long  and  repeated  observation  of  facts, 
ho  is  only  able  to  cite  a  much  smaller  number,  especially  when,  on  searching 
for  these  a  second  time,  they  cannot  be  found  ?  I  am  well  aware  that  facts  of 
exception  are  worthy  of  notice,  but  still  they  ought  to  be  verified. — Aniral. 

*  Andral  says  (Clin.  Med.  t.  iii.  p.  v.)  that  the  speck  does  not  always  appear 
first  in  the  centre,  but  sometimes  even  on  the  surface. —  Transl. 


288  PHTHISIS    PULMONALIS. 

they  sometimes  singly  acquire  the,  size  of  a  cherry-stone,  a  fil- 
bert, and  even  an  almond.  They  very  seldom  exceed  this  last 
size ;  and  the  larger  tuberculous  masses  are  usually  either  the 
product  of  several  tubercles  united,  or  of  the  tuberculous  infil- 
tration. In  general,  we  consider  it  a  sign  that  the  isolated  tu- 
bercles have  originated  in  a  single  point  or  granule,  when  we 
find  them  retaining  their  primitive  roundish  or  ovoid  shape. 

The  pulmonary  tissue  around  the  miliary  tubercles  is  usually 
perfectly  sound  and  crepitous,  and  this  the  more  so  according  as 
they  are  small  in  size  and  of  recent  formation. 

Granular  tubercles,  or  miliary  granulations. — This  rare  va- 
riety of  tubercle  was  described  for  the  first  time  by  Bayle,  and 
on  account  of  its  very  peculiar  character,  was  considered  by 
him  as  an  accidental  production  different  from  that  of  tubercles. 
These  granulations  are  nearly  of  the  size  of  a  millet  seed  ;  they 
are  exactly  round  or  ovoid,  and  differ  still  further  from  common 
tubercles  by  the  uniformity  of  their  size",  their  want  of  color, 
and  their  transparency.  They  are  commonly  disseminated  in 
countless  numbers  over  the  whole  extent  of  one  lung,  or  a  great 
part  of  it,  without  being  at  all  found  to  coalesce  in  groups.  Some- 
times, however,  from  their  vast  number  and  proximity  to  each 
other,  they  constitute  solid  masses  or  nodules ;  but  when  these 
are  cut  into,  we  find  the  granulations  all  distinct  and  separated 
from  each  other  by  cellular  substance,  which  is  either  quite 
sound,  or,  at  most,  only  slightly  injected  with  serum.  Bayle  was 
evidently  mistaken  in  considering  these  granulations  as  different 
from  tubercles,  and,  still  more,  in  regarding  them  as  accidental 
cartilages.  (Op.  Cit.  p.  48.)  Had  this  latter  opinion  been  well 
founded,  we  should  sometimes  see  them  pass  into  the  state  of 
bone,  which  is  never  the  case.  On  the  contrary,  if  we  examine 
these  bodies  attentively,  we  shall  be  convinced  that  they  pass  into 
yellow  and  opaque  tubercles.  Even  when  they  are  most  trans- 
parent and  colorless,  we  find  some  of  them  with  an  opaline  or 
slight  greyish  tint,  which  assimilates  them  with  the  common  tu- 
bercles. In  cutting  into  these  we  find  their  centre  yellow  and 
opaque,  a  sufficient  proof  of  their  incipient  transformation  into 
the  yellow  crude  tubercle.*  Bayle  himself  (obs.  iv.)  cites  a  re- 
markable instance  of  this.  We  find  also,  in  other  cases,  the 
lungs  filled  with  tubercles,  all  very  small,  and  equal  sized,  but 

*  Bayle's  opinion,  as  far  as  relates  to  the  difference  of  granulations  and  tuber- 
cles, but  not  as  to  the  former  being  of  a  cartilaginous  nature,  is  maintained  by 
Chomel  (Diet,  de  Med.  t.  x.  p.  345)  and  by  Andral  (Clin.  Med.  t.  iii.  p.  5.)  Both 
these  writers  adduce  several  reasons  for  being  of  this  opinion.  Among  others, 
Chomel  says,  that  the  granulations  never  coalesce  like  tubercles ;  and  Andral 
says,  they  exist  very  frequently  in  the  lower  lobes,  and  asks,  if  they  are  tuber 
cles,  why  it  happens  that  they  never  give  rise  to  large  tuberculous  excavations 
in  this  situation?  Louis,  however,  a  much  higher  authority  on  this  point, 
(Recherches,  p.  3,)  agrees  with  Lacnncc. —Transl. 


PHTHISIS     PULMONALIS. 


289 


yellow  and  opaque,  and  sometimes,  in  a  well-marked  state  of 
softening.  Bayle  (obs.  xvi.)  gives  an  instance  of  this  also ;  and 
although  he  warns  us  not  to  confound  these  miliary  tubercles 
with  the  granulations,  it  appears  to  me  clear,  that  the  only  dif- 
ference between  them  is  that  which  exists  between  a  ripe  and  a 
green  fruit.  Besides,  these  miliary  granulations  are  never  met 
with  except  in  lungs  in  which  there  exists  at  the  same  time  other 
tubercles  of  a  larger  size,  and  sufficiently  advanced  to  render 
their  character  no  longer  matter  of  question.  The  development 
of  tubercles  in  other  organs  presents,  also,  a  series  of  facts  suffi- 
cient to  prove,  that  in  their  first  state  and  when  recent,  they  are 
always  diaphanous  or  semi-transparent  and  colorless,  or  of  a 
slight  grey  color.  On  the  surface  of  the  pleura  and  peritoneum, 
they  are  sometimes  colorless  and  quite  transparent,  at  other 
times  grey  and  only  semi-transparent.  In  both  cases  they  have 
often  an  opaque  yellow  point  in  the  centre  ;  and  sometimes  we 
even  find  them  converted  into  tuberculous  matter  more  or  less 
softened.  It  is  by  no  means  rare  to  observe  all  these  different 
stages  on  the  same  membrane.  In  the  intestine  ulcers  of  phthi- 
sical subjects  we  commonly  find  miliary  tubercles,  with  the  same 
variety  of  color  and  transparency.  Around  the  tubercles  which 
are  found  in  lymphatic  glands,  we  also  observe  a  slight  semi- 
transparency  and  a  pearl-grey  tint,  indicative  of  the  approaching 
complete  transformation  of  the  gland  into  tuberculous  matter. 
Finally,  Bayle  found  the  spleen  filled  with  small  greyish  bodies, 
which  he  himself  regarded  as  tubercles.  (Obs.  xii.)*  Bayle's  error 

*  MM.  Andral  and  Chomel  were  the  first  to  deny  this  identity  of  granulations 
in  other  organs  with  those  in  the  lungs  ;  the  former  endeavoring  to  prove  that 
the  pulmonary  granulations  were  merely  the  air-cells  indurated  and  hypertro- 
phied,  (Clin.  Med.  t.  iii.  p.  5,)  the  latter  giving  no  reasons  for  his  opinion  (Diet, 
de  Med.  t.  x.  art.  granulation.)  M.  Andral  says,  these  apparent  granulations 
are  only  met  with  on  the  free  surfaces  of  the  serous  and  mucous  membranes, 
and  are,  in  the  former  case,  the  rudiments  of  false  membranes,  and  in  the  latter 
hypertrophied  follicles.  (Precis.  (VAnat.  Path.  t.  i.  p.  411.)  In  opposition  to 
these  opinions,  I  would  adduce  the  facts  (1)  that  granulations  are  met  with  in  in- 
testinal ulcers  with  complete  destruction  of  the  mucous  membrane;  (2)  that 
those  met  on  the  surface  of  serous  membranes  are  always  deposited  in  false 
m embrace.  Adopting  the  hypothesis  of  M.  Andral,  we  must  therefore  admit 
that  mucous  follicles  may  exist  without  mucous  membrane,  and  that  the  rudi- 
ments of  false  membrane  may  be  enclosed  within  other  false  membranes. — 
(M.  L.) 

All  that  I  have  affirmed,  and  still  maintain,  is,  that  we  have  too  carelessly 
compared  to  pulnionarv  granulations,  other  lesions  which  have  no  similarity  to 
them  except  in  shape.  I  am  still  convinced  that  under  this  name,  descriptions 
have  been  given  of  mere  follicles  in  the  intestines  which  have, become  more 
apparent  than  common,  and  jut  out  more  or  less  on  the  free  surface  of  the 
mucous  membrane.  I  think  also  that  on  the  serous  membranes  in  a  state  of 
chronic  inflammation,  and  especially  on  the  peritoneum,  the  false  membranes 
oAen  begin  to  appear  in  the  shape  of  little  grains  isolated  from  each  other,  and 
that  these  grains  have  been  erroneously  considered  of  the  same  nature  with  the 
granulations  in  the  lunga  It  is  not  uncommon  to  find  similar  granulations  on 
the  parietes  of  the  cerebral  ventricles,  in  cases  of  chronic  meningitis  ;  and  this 
37 


290  PHTHISIS     PULMONAL1S. 

in  respect  of  these  granulations  arose  from  his  not  having  suf- 
ficiently distinguished  the  grey  and  semi-transparent  matter 
which  constitutes  tubercles  in  their  early  or  crude  state.  Several 
of  his  cases,  however,  particularly,  the  6th,  12th,  13th,  and 
24th,  show  that  he  observed  this,  but  without  ascertaining  the 
relation  which  it  bears  to  the  yellow  and  opaque  tubercles.  It 
is  moreover  worthy  of  remark  in  this  place,  that  all  the  acci- 
dental productions  which  have  no  analogy  with  the  natural  tex- 
tures of  the  body,  in  their  earliest  stage,  present  the  same  semi- 
transparency,  and  are  equally  hard,  with  the  single  exception  of 
melanosis.  May  we  conceive  that  this  lardaceous  matter,  as  it 
was  called  by  the  ancients,  so  little  varied  in  the  different  acci- 
dental productions,  may  be  for  them  what  the  yolk  of  the  egg  is 
to  the  chick,  and  the  primitive  animal  jelly  to  the  organs  formed 
in  it, — viz.  a  sort  of  a  matrix  destined  to  receive  materials  foreign 
to  the  natural  organization  of  the  part,  the  consequence  of  some 
aberration  of  nutrition  ? 

Independently  of  the  stages  of  development  above  mentioned, 
certain  accidental  circumstances  may  change  the  color  of  tuber- 
cles. Jaundice  stains  them  yellow,  particularly  on  their  surface ; 
and  this  is  especially  the  case  when  they  are  situated  in  the  liver. 
Gangrene  in  their  vicinity  gives  them  a  brownish  or  dirty  brown 
color.  The  black  pulmonary  matter  sometimes  stains  them 
partially,  intermixing  some  black  or  grey  points  ^ith  their  yel- 
lowish white.  It  is  even  probable  that  the  grey,  color  of  the 
tubercles  in  their  first  stage  of  crudity  and  transparency,  is  owing, 
at  least  in  part,  to  an  admixture  of  a  small  portion  of  the  same 
black  matter.  I  have  thought  that  I  had  observed  in  the  cases 
where  the  miliary  granulations  were  most  transparent,  the  quan- 

pathological  fact,  by  the  way,  seems  to  me  to  establish  at  least  an  analogy 
between  the  membrane  which  lines  the  interior  of  the  cerebral  ventricles  and 
the  serous  membranes.  All  this  being  established,  I  do  not  undertake  to  deny 
that  in  some  organs  a  peculiar  morbid  production  has  been  seen,  similar  to  that, 
described  by  Bayle,  in  the  lungs,  under  the  name  of  granulation,  and  I  readily 
allow  that  this  granulation  often,  if  not  always,  precedes  the  development  of 
the  tuberculous  matter.  But  what  I  think  certain  at  the  present  day,  as  at  the 
time  when  I  first  published  the  result  of  my  researches  on  this  subject,  is,  that 
the  lesion  described  by  Bayle  under  the  name  of  granulation,  is  often  nothing 
but  a  fragment  of  pulmonary  lobule  in  a  state  of  grey  induration  in  consequence 
of  inflammation. 

In  most  cases  it  is  very  easy  to  follow  the  different  phases  through  which  the 
tissue  of  the  lungs  passes,  to  arrive  at  this  appearance  which  gives  rise  to  the 
belief  of  the  existence  of  an  accidental  production  altogether  peculiar.  We  see 
at  first  red  points  merely  hyperaemiated,  scattered  throughout  a  certain  number 
of  lobules ;  other  points  are  likewise  red,  and  also  become  friable  and  imper- 
meable to  the  air  ;  others  exhibit  the  grey  color  and  induration  which  belong  to 
chronic  inflammation.  Who  does  not  see  that  these  various  alterations  are 
nothing  but  the  different  degrees  of  a  morbid  state  of  the  same  nature,  and  that 
if  the  fragment  of  lobule  hepatized  and  red,  cannot  be  called  an  accidental 
■product,  we  have  no  reason  for  giving  this  name  to  the  same  fragment  of  lobule 
when  it  has  become  grey  and  hard  ?—Jlndral. 


PHTHISIS    PULMONALIS.  291 

tity  of  blaok  pulmonary  matter  in  the  lungs  was  the  least.  The 
miliary  tubercles,  moreover,  whether  semi-transparent  or  opaque, 
have  a  black  point  in  their  centre,  which  usually  disappears  as 
they  enlarge.  I  formerly  remarked,  when  treating  of  the  bron- 
chial glands,  that  the  tubercles  which  form  in  them,  have  often 
in  their  interior  a  dash  of  black,  like  the  shading  of  a  crayon 
drawing,  very  deep  in  some  points,  and  gradually  vanishing  as  we 
recede  from  these. 

Grey  tuberculous  infiltration. — This  kind  of  infiltration  is  fre- 
quently formed  around  tuberculous  excavations.  We  sometimes 
also  find  it  existing  primitively  in  cases  where  no  tubercles  exist ; 
but  this  is  extremely  rare.  In  other  cases,  we  find  tuberculous 
masses  of  a  large  size,  in  the  first  or  semi-transparent  stage, 
without  any  previous  development  of  miliary  tubercles.  These 
masses  are  dense,  humid,  quite  impermeable  to  air,  and  of  a  more 
or  less  deep  grey  color.  When  cut  in  thin  slices,  they  are 
found  to  be  almost  as  compact  as  cartilage,  with  a  smooth  and 
polished  surface,  and  a  homogeneous  texture,  in  which  the  vesi- 
cular structure  of  the  lung  is  no  longer  perceptible.  In  pro- 
portion as  they  advance  towards  softening,  we  observe  a  quantity 
of  small  yellow  opaque  specks  make  their  appearance,  which, 
gradually  increasing  in  number  and  size,  at  length  involve  the 
whole  mass,  and  convert  it  into  yellow  tuberculous  matter.  This 
species  of  grey  tuberculous  infiltration  has  been,  of  late  years, 
mistaken  by  inexperienced  observers,  for  chronic  pneumonia. 
We  shall  presently  notice  the  anatomical  characters  by  which 
this  degeneration  diners  from  inflammation. 

Jelly-like  tuberculous  infiltration. — In  the  intervals  of  the 
miliary  tubercles  we  very  frequently  observe  an  infiltration,  usu- 
ally of  small  extent,  of  a  matter  which  may  be  said  to  be  very 
humid  rather  than  fluid,  which  is  colorless,  or  slightly  sangui- 
neous, and  has  more  the  appearance  of  a  fine  jelly  than  of  com- 
mon serosity.  We  might  be  tempted  in  some  instances  to  con- 
sider this  as  mere  oedema,  formed  by  a  very  viscid  lymph,  were 
it  not  that  we  can  distinguish,  with  great  difficulty,  or  not  at  all, 
the  natural  alveolar  structure  of  the  lungs  amid  the  gelatinous 
mass.  By  degrees  this  substance  acquires  greater  consistence,  and 
is  gradually  and  insensibly  transformed  into  the  tuberculous  mat- 
ter which  I  have  been  describing  above.  Where  this  substance 
is  most  transparent  and  fluid,  we  frequently  observe  in  it  small 
yellow  points,  evidently  of  a  tuberculous  character,  and  finally, 
we  trace  it  through  all  the  stages  of  the  common  tuberculous 
degeneration.  For  these  reasons,  I  consider  this  jelly-like  sub- 
stance as  a  mere  variety  of  the  semi-transparent  grey  tubercu- 
lous matter ;  although  it  also,  like  the  last  variety,  has  been  re- 
cently mistaken  for  a    product  of  chronic   inflammation.     The 


292  PHTHISIS    PULMONALIS. 

conversion  of  the  grey  and  gelatinous  infiltration  into  yellow 
tuberculous  matter,  is  sometimes  so  rapid,  that  in  examining 
lungs  containing  very  large  masses  of  the  latter,  we  sometimes 
find  no  trace  of  the  former,  although  there  can  be  no  doubt  that 
the  one  originated  in  the  other.  This  form  of  the  tuberculous 
infiltration  is  found  in  different  points  of  the  lungs,  in  masses  of 
a  yellowish  white  color,  and  much  paler,  duller,  and  less  dis- 
tinct from  the  substance  of  the  lungs  than  the  common  crude  tu- 
bercles. These  masses  are  irregular,  angular,  and  never  have 
the  nearly  round  shape  of  ordinary  tubercles.  Like  the  variety 
described  in  the  last  paragraph,  and  the  diffused  grey  matter 
formerly  noticed,  they  appear  to  be  produced  by  a  kind  of  infil- 
tration of  the  tuberculous  matter  into  the  pulmonary  tissue ; 
whilst  the  common  round  tubercles  are  foreign  bodies,  which  sep- 
arate and  press  aside  the  substance  of  the  viscus,  on  all  sides, 
rather  than  penetrate  into  its  parenchyma.  These  masses  occa- 
sionally occupy  a  considerable  part  of  one  lobe,  without  at  all 
altering  its  shape,  or  producing  any  protuberance  on  its  surface. 
In  their  progress  they  become  first  yellow,  and  finally  soften  like 
common  tubercles.*  t 

*  M.  Laennec's  views  regarding  the  primary  state  of  tubercles  and  the 
mode  of  their  development,  has  been  called  in  question  by  various  pathologists. 
Indeed  the  researches  of  Majendie  (Jour,  de  Med.  t.  i.  1821)  ;  of  Cruveilhier 
(Med.  Eclairee,  &c.  Par.  1821 ;  Nouv.  Bib.  Med.  Sep.  et  Nov.  1826)  ;  of  Andral 
(Clin.  Med.  t.  iii. ;  Diet,  de  Med.  t.  xvi.  art  Phthisie.  t.  xx,  art.  Tubercle;  Precis 
d'Anat.  Path.) ;  of  Lombard  (Essai  sur  les  tubercles,  Par.  1827) ;  and  of  Boul- 
land  (Recherches  sur  les  Tiss  sans,  analog.  Journ.  des  Progr.  t.  iv.  1827)  ;  all  tend 
to  establish  the  proposition,  that  tubercle,  instead  of  being  an  accidental  produc- 
tion possessing  a  proper  vitality,  and  developing  itself  by  intussusception,  like 
organized  tissues,  is,  in  fact,  the  result  of  morbid  secretion — a  peculiar  species 
of  pus — an  inorganic  product  formed  by  juxtaposition  ;  the  tubercle  is  in  the  first 
instance  liquid,  but  speedily  concretes  under  the  form  of  minute  round  grains, 
which  are  friable,  opaque,  yellowish,  isolated  or  in  groups,  encysted  or  free,  and 
which,  after  a  certain  time,  assume  once  more  the  liquid  form,  or  become,  at 
least,  soft ;  that  in  place  of  this  softening  process  proceeding  regularly  from  the 
centre  to  the  circumference,  it  is  found  to  commence  at  any  point  indifferently, 
the  liquefaction  being  the  consequence  of  a  fresh  purulent  secretion  occasioned 
by  the  presence  of  the  tubercle  acting  as  a  foreign  body ;  that  there  is  no  such 
thing  as  a  distinct  grey  tubercle, — what  has  been  mistaken  for  this  being  a  mere 
variety  of  chronic  inflammation,  a  simple  hypertrophy  of  the  natural  tissues, 
within  which  true  tubercle  is  frequently  developed,  but  by  no  means  as  a  neces- 
sary consequence  5  that  the  tubercular  secretion,  like  every  other  secretion, 
takes  place  under  the  influence  of  active  sanguineous  congestion,  and  may,  like 
that  of  pus,  succeed  to  a  local  inflammation  or  a  mechanical  irritation,  but  that 
it  occurs  more  commonly  in  consequence  of  a  general  predisposition,  congenital 
or  acquired,  and  which  predisposition  seems,  in  its  turn,  to  be  the  result,  at  least 
most  frequently,  of  an  altered  condition  of  the  fluids  ;  filially,  that  the  cellular 
tissue  is  the  most  common,  if  not  the  exclusive  site  of  the  tuberculous  secretion. 

I  cannot  here  detail  the  facts,  more  or  less  questionable,  upon  which  this  very 
specious  theory  of  tuberculization  rests,  which,  by  the  way,  is  fundamentally  a 
mere  paraphrase  of  that  of  M.  Broussais.  I  will  only  remark,  that  if  we  regret 
the  existence  of  the  grey  tuberculous  matter,  and  regard  the  phenomenon  asa 
simple  hypertrophy  of  the  tissues,  the  consequence  of  a  chronic  inflammation,  we 
must,  at  least,  acftnit  that  this  hypertrophy  necessarily  precedes  the  development 


PHTHISIS    PULMONALIS. 


293 


In  whatever  manner  the  crude  tubercles  are  formed,  after  a 
very  variable  period  of  time  they  finally  become  soft   and  fluid. 

of  the  yellow  tubercles,  or  else  we  must  reject  one  of  the  most  legitimate  de- 
ductions in  pathological  anatomy;  we  must  further  admit  (what  appears  to  me 
in  opposition  to  all  just  observation)  that  a  tissue,. in  simply  augmenting  its  vol- 
ume may  become  so  altered  in  form  as  to  retain  no  trace  of  its  primitive  or- 
ganization. 

Other  observers,  without  rejecting  all  that  Bayle,  Laennec,  Louis,  and  others, 
regarded  as  established,  have  advanced  the  opinion  that  the  grey  is  not  the 
first  but  the  second  stage  of  the  yellow  tubercle,  being  preceded  by  a  red  or 
reddish  yellow  body  of  the  size  of  from  one-fourth  to  a  whole  millet  seed,  pretty 
solid  and  resisting,  being  flattened  under  the  nail  without  any  escape  of  fluid, 
and  attached  to  the  surrounding  tissue  by  a  mass  of  cellular  or  vascular  fila- 
ments constituting  a  sort  of  tomentum,  or  down  around  them.  According  to  M. 
Rochoux,  who  has  most  carefully  described  these  bodies,  although  they  had 
been  previously  noticed  by  Dalmazzone,  (Ripet.  di  Medic,  fyc.  Nov.  1826,)  the 
grey  tubercle  first  begfns  to  show  itself  at  their  centre,  i«  the  same  point  where 
the  subsequent  softening  of  the  yellow  tubercle  commences.  The  tomentose 
or  downy  envelop  of  these  nascent  tubercles  (which  present  no  traces  of  organ- 
ization) uniting  them,  as  by  radicles,  to  the  tissue  in  which  they  are  developed, 
indicate  them  as  being  the  result  of  an  organic  process,  by  means  of  which  the 
primary  form  of  the  particular  tissue  has  been  made  to  disappear  at  the  same 
time  that  the  new  materials  have  been  incorporated  with  it :  in  other  words, 
that  there  has  been  a  real  removal  of  tissue,  and  not  a  mere  dUplacement  of  it. 
(Bull  Univ.  des  Sc.  Aou.,  1829.)  M.  Rochoux  is  disposed  to  conclude  from  his 
researches  that  tubercle  is  neither  an  accidental  production  nor  a  secreted  mat- 
ter, but  a  degeneration  or  transformation  of  a  healthy  tissue  into  a  morbid  one. 
This,  then,  is  a  third  theory  of  tuberculization  quite  as  specious  as  the  last. 

A  fourth  theory,  not  mentioned  by  Laennec,  although  he  was  well  acquainted 
with  it,  is  that  of  Dr.  Baron,  who  contends  that  all  tubercles  are  in  their  origin 
transparent  vesicles  or  hydatids.  (On  the  nature  of  Tuberculated  Accretions,  fyc. 
Lond.  1819;  Illustrations  of  the  Enquiry  respecting  Tuberculous  Diseases. 
Lond.  1822.) — This  opinion  is  evidently  that  of  a  man  little  versed  in  there- 
searches  of  pathological  anatomy,  and  more  conversant  with  slaughter-houses 
than  dissecting  rooms,  who  has  not  been  able  to  discriminate  the  distinctive  pro- 
gress and  development  of  each  of  two  morbid  alterations  frequently  co-existing. 
There  is  only  one  professed  anatomist  who  has  appeared  to  adopt  this  opinion  of 
Dr.  Baron,  and  it  is  remarkable  that  he  is  one  whose  researches  have  been  more 
in  comparative  than  human  anatomy.  (Dupuy.  De  L'Affect.  Tubcrc.  vulg.  ap- 
pelce  Morve,  &c.  Par.  1807.)  M.  Dupuy  has  however,  been  very  reserved  in 
stating  his  opinions,  contenting  himself  with  saying,  that  he  has  found  tubercles 
and  hydatids  co-existing  in  the  same  subjects,  and  often  in  the  same  viscus,  and 
that  he  has  sometimes  seen  in  the  cysts  which  contained  hydatids  incipient  de- 
posites  of  tuberculous  matter,  a  circumstance  which  would  lead  us  to  imagine 
that  the  one  might  succeed  the  other. — (M.  L.) 

The  last  writer  on  the  subject  of  Tubercle,  and  one  whose  talents,  industry, 
and  most  extensive  opportunities,  entitle  his  authority  to  the  greatest  considera- 
tion, is  Dr.  Carswell ;  and  I  shall  conclude  this  note  with  a  brief  notice  of  his 
opinions,  as  recorded  in  the  first  fasciculus  of  his  invaluable  wor'c  on  Patholo- 
gical Anatomy  ;  and  in  the  article  Tubercle  in  the  4th  .volume  of  the  Cyclope- 
dia of  Pract.  Med.  It  will  he  seen,  that  they  accord,  in  some  respects,  with 
those  of  Andral,  and  Cruveilhier,  and  Lombard,  but  differ  in  others.  1.  The 
scat,  of  tubercle  may  be  any  of  the  tissues,  but  the  mucous  tissue  is  by  far  the 
most  frequent  depository.  2.  The  form  of  tubercle  is  entirely  dependent  on 
the  condition  of  the  parts  where  it  is  deposited  ;  it  more  commonly  affects  the 
rounded  form,  because  the  equal  pressure  of  contiguous  parts  in  certain  localities 
naturally  tend  to  produce  this  shape.  3.  The  consistence  of  tubercle  varies 
with  the  period  of  its  existence,  the  relations  of  the  surrounding  parts,  &c. ;  at 
its  first  deposition  it  is  often  fluid,  or  of  the  consistence  of  soft  cheese  intermixed 
with  water.  4.  The  grey  semi-transparent  condition  of  tubercle  is  by  no  menus 
a  necessary  precursor,  as  Laennec  imagines,  of  the  yellow  tubercle,  as  this  con- 


294  PHTHISIS    PULMONALIS. 

The  process  begins  in  the  centre  of  each  mass,  and  gradually  in- 
creases, the  tuberculous  matter  becoming  daily  softer  and  mois- 
ter,  cheesy,  at  least  unctuous  to  the  touch  like  soft  cheese,  and 
finally  acquires  the  viscidity  and  fluidity  of  pus.  The  soften- 
ing gradually  attains  the  surface,  and  at  last  involves  the  whole 
mass. 

In  this  stage  the  tuberculous  matter  is  of  two  different  kinds 
in  appearance ; — the  one  resembling  thick  pus,  but  without 
smell,  and  yellower  than  the  crude  tubercle  ;  the  other,  a  mixed 
fluid,  one  portion  of  it  being  very  liquid,  more  or  less  transpa- 
rent, and  colorless,  unless  tinged  with  blood,  and  the  other  por- 
tion opaque,  of  a  caseous  consistence,  soft  and  friable.  In  this 
last  condition,  which  is  chiefly  observable  in  strumous  subjects, 
the  fluid  often  perfectly  resembles  whey  having  small  portions  of 
curd  floating  in  it.  When  the  softening  of  the  tuberculous  mass 
is  completed,  this  finds  its  way  into  some  of  the  neighboring 
bronchial  tubes  ;  and  as  the  opening  is  smaller  than  the  excava- 
tion, both  it  and  the  latter  remain,  of  necessity,  fistulous,  even 
after  the  complete  evacuation  of  the  tuberculous  matter.*     It  is 

dition  is  only  observed  in  few  of  the  many  organs  where  yellow  tubercle  is 
found.  The  following  quotation  will  at  once  explain  Dr.  Carswell's  view  of 
the  manner  in  which  tuberculous  matter  is  secreted  generally,  and  his  manner 
of  accounting  for  the  peculiar  character  of  one  form  of  the  pulmonary  tuber- 
cle : — "  It  is  obvious  that  a  healthy  secreting  surface  may  separate  from  the 
blood  not  only  the  materials  of  its  own  peculiar  secretion,  but  also  those  of  tu- 
berculous matter.  Such  is,  indeed,  what  takes  place  in  the  air-cells.  The  mu- 
cous secretion  of  their  lining  membrane  accumulates  where  it  is  formed  ;  but  it 
is  not  pure  mucus  ;  it  contains  a  quantity  of  tuberculous  matter  mixed  up  with 
it,  which,  after  a  certain  time,  is  separated,  and  generally  appears  in  the  form 
of  a  dull  yellow,  opaque  point,  occupying  the  centre  of  the  grey,  semi-trans- 
parent, and  sometimes  inspissated  mucus."  5.  Tubercle  is  completely  inorganic 
and  incapable  of  alteration  except  from  external  agency ;  softening  therefore 
takes  place  from  the  effect  of  the  pus,  <fec.  secreted  around  it:  this  process  con- 
sequently commences  commonly  at  the  surface.  The  following  is  the  explana- 
tion given  by  Dr.  Carswell  of  the  mistake  made  by  Laennec  as  to  the  com- 
mencement of  softening  in  the  centre  : — "  When  tuberculous  matter  is  formed  in 
the  lungs,  it  is  generally  contained  in  the  air-cells  and  bronchi.  If,  therefore, 
this  morbid  product  is  confined  to  the  surface  of  either,  or  has  accumulated  to 
such  a  degree  as  to  leave  only  a  limited  central  portion  of  their  cavities  unoc- 
cupied, it  is  obvious  that  when  they  are  divided  transversely,  the  following 
appearances  will  be  observed  :  1.  A  bronchial  tube  will  resemble  a  tubercle 
having  a  central  depression  or  soft  central  point,  because  of  the  centre  of  the 
tube  not  being,  or  never  having  been,  occupied  by  tuberculous  matter,  and  be- 
cause of  its  containing  a. small  quantity  of  mucus  or  other  secreted  fluids  ;  2.  the 
air-cells  will  exhibit  a  number  of  similar  appearances  or  rings  of  tuberculous 
matter  grouped  together  and  containing  in  their  centre  a  quantity  of  similar 
fluids.  When  the  bronchi,  or  air-cells,  are  completely  filled,  the  tuberculous 
matter  presents  no  such  appearance;  and  hence  the  reason  why  tubercle,  in 
such  circumstances,  has  been  said  to  be  still  in  the  state  of  crudity,  or  that  con- 
dition which  precedes  the  softening  process."  (Pathol.  Anat.  FazscA.)  6.  The 
term  encysted  is  almost  always  incorrect :  in  the  lungs,  it  is  generally  the  dis- 
tended walls  of  the  air-cells  which  have  been  mistaken  for  cysts.  7.  The  cure 
of  pulmonary  tubercle  by  cicatrization,  as  explained  by  Laennec,  is  fully  corro- 
borated by  the  observation  of  Dr.  Carswell.—  Transl. 
*  When  the  tuberculous  excavations  are  very  near  the  thoracic  pariete*,  they 


PHTHISIS    PULMONALIS. 


295 


extremely  rare  to  find  only  one  such  excavation  in  a  tuberculous 
lung.  Most  commonly  the  cavity  is  surrounded  by  tubercles  in 
different  stages  of  their  progress,  which,  as  they  successively 
soften,  discharge  their  contents  into  it,  and  thus  gradually  form 
those  irregular  and  continuous  excavations  so  frequently  observ- 
able, and  which  sometimes  extend  from  one  extremity  of  the 
lungs  to  the  other.  Bands,  composed  of  the  natural  tissue  of 
the  organ,  condensed,  as  it  were,  and  charged  with  the  tubercu- 
lous degeneration,  frequently  cross  these  cavities,  in  a  manner 
something  resembling  the  columna  cornea  of  the  ventricles. 
These  bands  are  of  less  dimensions  in  their  middle  than  at  their 
extremities,  and  have  often  been  mistaken  for  vessels.  M.  Bayle 
himself  seems  to  have  fallen  occasionally  into  this  error,  since  he 
says,  that  vessels  frequently  traverse  such  cavities  ;  whereas  this 
is,  in  my  opinion,  a  very  rare  circumstance.  Nay  more,  I  have 
never  even  found  a  vessel  of  any  consequence  included  within  the 
substance  of  these  bands.  Neither  is  there  any  example  of  this 
in  M.  Bayle's  work  ;  and  I  only  remember  to  have  heard  him 
mention  one  case  where  this  took  place,  viz.  in  a  fatal  haemoptysis, 
where  the  ruptured  vessel  was  found  crossing  a  very  large  ca- 
vity. In  the  very  few  cases  where  I  have  found  blood  vessels  in 
such  bands,  they  constituted  only  a  small  portion  of  their  mass, 
and  were,  for  the  most  part,  obliterated.  Generally,  indeed, 
they  can  only  be  traced  for  a  small  space  into  these  columns, 
being  soon  undistinguishable  from  the  pulmonary  tissue  injected 
with  the  tuberculous  substance.*  It  would  appear  that  the  tu- 
bercles, during  their  increase,  press  on  one  side,  and  separate 
the  blood  vessels,  as  we  find  these,  sometimes  of  considerable 
size,  lining  the  internal  surface  of  the  cavities,  and  forming  a 
part  of  them.  These  vessels  are  generally  flattened,  but  rarely 
obliterated :  their  smaller  ramifications,  however,  which  stretch 
towards  the  tuberculous  excavations,  or  towards  unevacuated 
tubercles,  are  evidently  so,  as  is  proved  by  our  abortive  attempts 
to  throw  an  injection  through  them  into  the  excavations.  Dr. 
Baillie  had  already  made  the  same  observation ;  and  Dr.  Stark 
appears  to   have   found  these  vessels  obliterated  by  coagulated 

may  while  opening  into  the  bronchi,  communicate  also  at  the  exterior  in  another 
manner.  I  have  in  fact  seen  an  individual  with  a  fistula  in  an  intercostal  space, 
which  led  to  a  vast  cavity  whose  anterior  wall  was  formed  by  condensed  cellular 
tissue  on  the  ribs :  this  person  lived  several  months  with  this  fistula,  through 
which  the  air  might  be  heard  to  escape  with  a  hissing  sound  during  respiration. 
M.  Voisin,  formerly  of  the  St.  Louis  Hospital,  has  published  in  the  Revue 
Medicale,  July  1831,  the  case  of  a  consumptive  person  with  a  cavity  communi- 
cating thus  with  the  exterior  by  a  fistulous  passage  opening  over  the  clavicle  of 
the  corresponding  side. — An&ral. 

*  Louis  (Op.  Cit.  p.  12)  says  he  has  only  met  with  five  cases  in  which  vessels 
were  discoverable  in  these  bands. —  Transl. 


296  PHTHISIS    PULMONALIS. 

blood.*  The  ramifications  of  the  bronchi,  on  the  contrary, 
seem  rather  enveloped  than  pressed  aside  by  the  tuberculous 
matter ;  and  it  would  appear  that  the  pressure  soon  obliterates 
their  canal,  as  they  are  hardly  ever  to  be  detected  in  the  morbid 
substance.  That  they  must,  nevertheless,  have  originally  tra- 
versed the  spaces  now  occupied  by  the  tubercles,  seems  proved 
by  the  fact,  that  in  every  excavation  even  the  smallest,  we  find 
one  or  more  bronchial  tubes  opening  into  it.  These  tubes 
scarcely  ever  open  sideways,  but  are  cut  directly  across,  on  a 
line  with  the  internal  surface  of  the  excavation  ;  and  their  direc- 
tion is  such  as  shows  them  to  have  originally  crossed  this  space. 

In  proportion  as  an  excavation  discharges  its  contents,  its 
walls  become  covered  with  a  species  of  morbid  or  false  mem- 
brane, thin,  smooth,  white,  nearly  quite  opaque,  of  a  very  soft 
consistence,  and  almost  friable,  so  that  it  can  readily  be  scraped 
off  with  the  scalpel.  This  membrane  is  generally  quite  perfect, 
covering  the  whole  internal  surface  of  the  cavity.  Sometimes, 
in  place  of  that  just  described,  we  find  a  membranous  exudation, 
thinner,  more  transparent,  less  friable,  more  intimately  connected 
with  the  walls  of  the  cavity,  and  for  the  most  part,  lining  these 
only  in  part.  When  completely  investing  the  cavity,  it  presents, 
in  different  parts  of  its  surface,  points  here  and  there  of  greater 
prominence,  as  if  the  exudation  had  begun  in  these  different  spots 
at  the  same  time.  Frequently  we  find  this  second  membrane 
beneath  the  first,  which  last  is  then  quite  loose,  and  lacerated  in 
several  places.  Occasionally,  also,  both  these  membranes  are 
entirely  wanting,  and  the  walls  of  the  cavity  are  formed  directly 
by  the  natural  tissue  of  the  lungs,  which,  in  this  case,  is  commonly 
condensed,  red,  and  charged  with  tuberculous  matter  in  different 
stages  of  its  development. 

*  I  think  it  due  to  the  memory  of  Dr.  Stark  to  state  that  he  noticed  and  accu- 
rately described  the  early  appearance  and  progressive  development  of  tubercles 
in  the  lungs,  long  before  they  attracted  the  attention  of  the  French  pathologists. 
See  the  extract  from  his  MS.  read  before  tbe  Society  for  promoting  Medical 
Knowledge,  January  13,  1784,  and  published  the  same  year  in  tbe  first  volume 
of  the  "Medical  Communications,"  p.  359.  The  best  previous  account  of  tuber- 
cles, are  those  by  IVrpfcr  (Miscel.  Cur.  vol.  xix.)  and  Desault  (Sur  les  Mai  Ve- 
ner,  &c.  Bordeaux,  1733.) — Transf. 

Although  in  reality  the  vessels  contained  in  the  bands  which  traverse  the 
cavities,  become  obliterated,  and  may  break  without  causing  any  considerable 
haemorrhage,  there  are  exceptions  to  this  rule  more  common  than  Laennec 
allows  :  and  it  is  surprising  that  in  his  long  course  of  observations,  he  has  never 
found  in  these  bands,  blood-vessels  of  a  certain  size,  to  use  his  own  language, 
and  that  he  has  never  seen  a  case  of  hemoptysis  produced  by  this  cause.  1 
have  known  several  examples  among  phthisical  patients  who  already  at  the  last 
stage  of  their  malady,  were  rapidly  carried  off  by  a  profuse  hemoptysis  :  they 
suddenly  threw  up  quantities  of  blood  and  expired.  These  are  similar  to  the 
cases  described  by  Bayle  to  Laennec.  In  two  children  who  died  in  the  manner 
above  stated  of  sudden  haemoptysis,  Dr  Tonnele,  of  Tours,  found  one  of  the 
large  branches  of  the  pulmonary  artery  opening  into  a  cavity.— (Journal  hebdo- 
madaire  dc  medicine,  Oct.  1829.) — Andral. 


PHTHISIS    PULMONALIS. 


297 


From  these  facts  it  appears  to  me  that  the  second  species  of 
false  membrane  just  mentioned,  is  only  the  first  stage  of  the  first 
species ;  and  that  when  this  is  fully  formed  it  is  apt  to  be  de- 
tached and  discharged  in  a  greater  or  less  degree, — forming  one 
portion  of  the  sputa  expectorated  by  the  consumptive.  Bayle 
thinks  that  this  false  membrane  secretes  the  pus  expectorated  in 
this  disease :  an  opinion  which  is  founded  on  the  analogy  exist- 
ing between  it  and  that  which  forms  on  the  surface  of  the  blisters 
and  ulcers.  It  seems  certain,  however,  to  me  at  least,  that  the 
greater  part  of  the  matter  expectorated  is  the  product  of  the 
bronchial  secretion,  augmented  as  this  is  by  the  irritated  condi- 
tion of  the  lungs.  I  do  not  assert  that  pus  is  not  formed' in 
these  tuberculous  excavations  at  all,  but  I  certainly  have  ob- 
served that  when  these  are  lined  by  the  soft  membrane  described 
above,  they  are  often  entirely  empty,  and  that  when  they  do 
contain  any  puriform  matter,  this  bears  by  no  means  so  great  a 
resemblance  to  the  sputa  as  that  does  which  is  contained  in  the 
bronchi.* 


*  Consumptive  patients  differ  much  from  each  other  in  this  respect.  In  some 
of  them  auscultation  gives  evidence  of  cavities  already  large,  yet  the  matter 
they  expectorate  no  way  differs  from  that  produced  by  the  most  simple  bron- 
chitis. In  these  persons,  how  large  soever  the  cavity  in  the  lung  may  be,  it  is 
the  seat  only  of  a  mild  and  moderate  secretion,  and  when  the  tuberculous  mat- 
ter is  evacuated,  the  quantity  of  pus  furnished  by  its  secreting  surface  is  too 
small  to  be  perceived  in  the  expectoration.  On  the  contrary,  there  are  others 
with  cavities  furnishing  continually  a  large  amount  of  secretion  :  with  these, 
the  sputa  have  an  aspect  altogether  peculiar  and  characteristic.  In  many  of 
these  cases,  if  the  pntient  only  lies  on  the  side  opposite  the  cavity,  he  will  ex- 
pectorate at  once  on  a  slight  effort  of  coughing,  a  large  quantity  of  purulent 
matter.  The  source  of  this  matter  can  then  be  no  longer  mistaken.  Thus  the 
sputa  may  often  furnish  by  their  appearance  and  the  manner  in  which  they  are 
thrown  up,  signs  not  to  be  neglected  :  at  the  same  time  it  must  not  be  forgotten 
that  pulmonary  phthisis  may  pass  through  its  different  stages,  and  arrive  at  a 
degree  of  ulceration,  without  any  expectoration  of  matter  different  from  that 
exhibited  by  the  mildest  catarrhal  affection. 

Finally,  the  pus  thrown  up  by  expectoration  may  come  from  other  sources 
than  a  tuberculous  cavity  :  an  abscess  in  the  lung,  a  gangrene  of  this  organ,  or 
a  simple  chronic  inflammation  of  the  mucous  membrane  of  the  bronchi,  (as  I 
have  shown  by  examples  in  my  Clinique  Medicate)  may  cause  an  expectoration 
of  pus  which  in  either  case  will  have  for  the  most  part  its  peculiar  character. 
A  purulent  effusion  in  the  cavities  of  the  pleura  may  also  force  itself  out  through 
the  bronchi,  and  thus  cause  an  expectoration  of  pus.  In  fine,  there  are  cases 
when  the  expectorated  pus  has  come  from  parts  other  than  the  chest :  thus  hy- 
datids in  the  liver  have  in  some  instances  forced  a  passage  through  the  dia- 
phragm, and  after  perforating  the  lung  and  some  of  the  bronchial  tubes,  have 
been  expectorated,  carrying  with  them  a  purulent  fluid  produced  in  the  liver 
among  the  entozoa.  ITr.  Arrow  Smith  has  also  given  in  the  London  Medical 
Gazette,  1834,  an  account  of  a  young  man  knocked  down  by  a  carriage,  who 
after  having  experienced  a  profuse  hemorrhage  from  the  mouth  and  rectum, 
exhibited  on  the  right  side  of  the  abdomen,  a  hard  tumor,  painful  on  pressure, 
and  yielding  a  dull  sound  on  percussion.  After  a  while  he  began  to  cough,  and 
on  the  twentieth  day  after  the  accident  he  suddenly  expectorated  nearly  a  pint 
of  purulent  matter,  and  continued  to  raise  nearly  the  same  quantity  for  nearly 
twenty  days.     At  this  period  the   purulent  expectoration  ceased,  but  was   re- 

38 


298  PHTHISIS    PULMONALIS. 

If  the  disease  remains  long  stationary,  there  are  at  length  de- 
veloped, in  different  points  under  this  false  membrane,  patches 
of  a  greyish  white  color,  semi-transparent,  of  a  texture  like  that 
of  cartilage,  but  somewhat  softer,  and  adhering  closely  to  the 
pulmonary  tissue.  These  patches  coalesce  as  they  grow  in  size, 
so  as  eventually  to  form  a  complete  lining  to  the  ulcerous  exca- 
vation, and  this  lining  seems  to  form  one 'continuous  surface  with 
the  internal  coat  of  the  bronchial  tubes  which  open  into  it. 
When  this  cartilaginous  membrane  is  completely  formed,  it  is 
commonly  white  or  of  a  pearl-grey ;  or  it  has  a  slight  reddish  or 
viojet  tint,  which  latter  color  is  derived  from  the  color  of  the 
subjacent  tissue  being  seen  through  it.  Sometimes,  however, 
even  when  the  membrane  is  of  considerable  thickness,  its  internal 
surface  is  of  a  rose  or  red  color,  which  does  not  yield  to  wash- 
ing, and  which  is,  therefore,  probably  occasioned  either  by  the 
vascularity  of  the  part,  (although  in  such  cases  I  have  never 
been  able  to  detect  any  distinct  vessel) — or,  more  probably  still, 
by  the  soaking  of  blood  after  death.  In  some  rare  instances  we 
find  tubercles  entirely,  or  almost  entirely,  softened,  in  a  portion 
of  lung  in  other  respects  quite  healthy  and  crepitous ;  and  in 
such  cases  (four  or  five  of  which  only  I  have  met  with  in  twenty- 
four  years)  the  walls  of  the  cavity  are  smooth,  and  seem  to  be 
formed  merely  in  the  pulmonary  tissue  somewhat  condensed,  there 
being  no  accidental  membranous  production  whatever.* 

placed  by  a  very  copious  fetid  diarrhoea  without  abdominal  pains.  This  con- 
tinued fifteen  days,  when  the  patient  died.  • 

On  opening  the  body,  the  following  lesions  were  found.  Directly  to  the  left 
of  the  left  lobe  of  the  liver,  and  behind  the  stomach,  was  a  vast  abscess  con- 
tained in  a  cyst,  above  which  the  diaphragm  was  perforated.  The  inferior  part 
of  the  right  lung  was  perforated  also,  and  a  large  bronchial  tube  opening  into 
the  abscess,  received  the  pus.  Elsewhere  the  lungs  were  perfectly  sound  :  the 
stomach  and  intestines  had  no  communication  with  the  abscess. 

I  have  quoted  in  my  Clinique  Medicaid,  the  case  of  a  man  in  whom  the  cavity 
of  the  stomach,  affected  with  cancer,  communicated  with  the  interior  of  the 
lung,  which  was  gangrened,  through  a  passage  involving  the  pleura,  the  dia- 
phragm and  the  spleen,  which  was  much  diseased.  During  life  there  were 
symptoms  of  pneumo-thorax. — Andral. 

*  Every  foreign  body  lodged  in  the  lungs,  causes  around  it  sooner  or  later  an 
irritation  which  brings  on  different  results,  most  commonly  a  suppuration  :  the 
tissue  of  the  lungs  becomes  ulcerated,  some  of  the  bronchial  tubes  open,  and 
the  foreign  body  forces  a  passage  out.  This,  however,  is  not  always  the  process. 
M.  Broussais  has  given  an  account  of  a  person  with  a  bullet  lodged  in  the  pa- 
renchyma of  the  lungs,  near  the  origin  of  the  bronchi:  it  was  contained  in  a 
very  smooth  cyst  ichich  it  exactly  filled.  The  lung  which  contained  the  bullet, 
presented  seven  or  eight  abscesses  filled  with  pus,  some  of  which  might  con- 
tain a  hen's  egg.  This  individual  was  a  corporal,  aged  33  years,  of  a  strong 
constitution — he  received  a  ball  in  the  upper  portion  of  the  right  side  of  the 
neck,  and  it  left  no  mark  except  at  the  point  of  its  entrance.  During  the  first 
fortnight  he  could  swallow  nothing  which  did  not  run  out  of  the  wound,  wholly 
or  in  part.  Afterwards  deglutition  was  completely  restored,  and  cicatrization 
took  place  without  the  ball  being  extracted.  He  soon  after  began  to  cough,  but 
this  did  not  hinder  him  from  indulging  in  every  excess.  During  the  four  years 
which  followed,  he  had  a  habitual  dyspnoea  and  dry  cough  :  his  strength  gradu- 


PHTHISIS    PULMONALIS. 


299 


Encysted  Tubercles. — Sometimes,  but  very  rarely,  the  semi- 
cartilaginous  membrane  is  perceptible  before  the  softening  of  the 
tubercles,  and,  indeed,  seems  to  be  of  the  same  date  as  them- 
selves. This  is  the  encysted  tubercle  of  Bayle.  (Op.  Cit.  p.  21.) 
The  texture  of  these  cysts  is  entirely  cartilaginous,  only  a  little 
less  solid  than  cartilage,  and  they  belong,  therefore,  to  the  class 
of  imperfect  cartilages,  of  which  I  have  given  an  account  in 
another  place.*  They  adhere  firmly  by  their  exterior  surface, 
to  the  parts  which  surround  them,  so  as  only  to  be  separable 
by  the  knife,  or  by  forcible  detraction.  The  tuberculous  matter 
contained  in  these,  before  it  is  completely  softened,  adheres 
strongly  to  their  sides,  and,  when  it  is  removed,  these  are  seen 
to  be  smooth  and  polished,  though  more  or  less  uneven  or  rug- 
ged. These  encysted  tubercles  are  more  frequent  in  the  bron- 
chial glands  than  in  the  substance  of  the  lungs.f 

I  have  myself  never  seen  these  cysts,  whether  primitive  or 
secondary,  become  ossified ;  this  morbid  state  must,  therefore, 
be  very  rare  ;  but  I  have  in  my  possession  a  cyst  of  the  size  of 
a  hen's  egg,  converted  into  a  bony  substance,  which  was  found 
in  the  lungs  of  a  subject  who  seemed  to  have  died,  as  far  as  I 
could  learn,  of  phthisis.  In  this  case  the  imperfect  ossification 
appears  to  have  commenced  in  three  different  points ;  as  the  cyst 
is  composed  of  three  portions,  united  by  thin  plates  of  cartilage 
not  yet  affected  with  the  osteo-petrous  degeneration.  Bayle 
seems  also  to  have  found  some  bony  points  in  this  kind  of  cyst. 
(Op.  Cit.  p.  22.) 

When  there  exists  a  great  number  of  tubercles,  even  very 
small  ones,  in  the  lungs,  death  will  sometimes  take  place  before 
any  of  them  has  reached  such  a  degree  of  softness  as  to  have  their 
contents  discharged  into  the  bronchi,  and  consequently  to  leave 
any  ulcerous  excavation.  But  this  case  is  extremely  rare,  and 
never  occurs  unless  there  exists  along  with  the  phthisis,  some 
other  affection  equally  severe,  or  at  least  capable  of  accelerating 
the  fatal  event.  When,  on  the  contrary,  there  is  only  a  small 
number  of  tubercles,  we  sometimes  find  them  all  excavated  after 
death.  In  the  majority  of  cases,  however,  the  development  of 
the  tubercles  is  evidently  successive,  so  that,  on  examination,  we 
find  them  in  the  same  lung,  in  the  different  stages  formerly  de- 
scribed, viz.  1.  In  the  state  of  granulations,  either  grey  or  co- 
lorless, and  semi-transparent;  2.  grey,  but  large,  and  yellow 
and  opaque  in  the  centre ;  3.    yellow  and  opaque  throughout, 

ally  declined,  and  he  died,  having  exhibited  the'ordinary  marks  of  hectic  fever. 
The  right  lung  was  found  perfectly  sound ;  the  left  presented  the  lesions  above 
described.     (Bulletin  des  Sciences  Medicates,  April  1808.) — Andral. 

*  Diet,  des  Scienc.  Med.  Art.  Cartilages  Accidentels. 

t  These  encysted  tubercles  have  been  seen  only  once  by  Louis;  (Op.  Cit.  p. 
10. ;)  they  must,  therefore,  as  Laennec  says,  be  very  rare. —  Transl. 


300  PHTHISIS    PULMONALIS. 

but  still  firm ;  4.  in  the  state  of  grey  tuberculous  infiltration,  ge- 
latinous, or  yellow ;  5.  softened,  especially  in  the  centre ;  6.  in 
the  state  of  excavations  more  or  less  completely  empty.*  These 
observations  are  important  in  a  therapeutical  point  of  view,  as 
we  shall  see  afterwards  ;  and  I  would,  therefore,  beg  to  call  the 
attention  of  the  practitioner  to  the  successive  development  of 
tubercles  in  the  different  parts  of  the  lungs.  They  begin  to 
show  themselves,  in  the  first  place,  almost  always  in  the  top  of 
the  upper  lobes,  more  particularly  in  the  right  ;f  and  it  is  in 
these  points,  especially  in  that  last  mentioned,  that  we  most  com- 
monly meet  with  the  tuberculous  excavations  of  vast  size.J  It 
is  by  no  means  uncommon  to  meet  with  cavities  of  this  kind,  in 
the  situation  just  named,  when  the  rest  of  the  lungs  are  quite 
sound,  and  do  not  contain  a  single  tubercle ;  but  in  this  class  of 
cases,  the  patient,  during  life,  has  frequently  exhibited  no  sign 
of  phthisis,  or  only  very  equivocal  ones,$  and  has  died  of  some 

*  The  almost  constant  coincidence  of  grey  granulations  and  yellow  tubercles 
is  confirmed  by  the  researches  of  Louis,  who,  out  of  358  subjects,  only  mot  with 
two  examples  of  tubercles  existing  without  granulations,  and  five  of  granulations 
•without  yellow  tubercles  ;  "  and  even  in  these  cases,"  he  says,  "  there  were  some 
granulations  more  or  less  yellowish  in  the  centre."  (Rechcrchcs,  p.  3.)  The 
same  observer  never  met  with  the  jelly-like,  matter  except  in  the  lungs  of  phthis- 
ical persons,  and  he  might  have  said  the  same  of  the  grey  matter  in  mass,  even 
while  admitting,  as  he  does,  with  M.  Chomcl,  that  the  last  may,  in  some  instan- 
ces, be  only  a  form  of  chronic  pneumonia.  In  making  this  remark,  I  must  ob- 
serve, 1st.  that  I  feel  a  difficulty  in  refusing  to  believe  that  two  alterations  so 
constantly  re-united,  have  some  necessary  connection  ;  and2nd,|that  if  this  co-ex- 
istence of  yellow  tubercles  with  granulations  or  grey  matter  in  mass,  is  met  with 
in  other  organs,  it  is  difficult  to  believe  that  the  latter  when  seated  in  the  lungs, 
is  merely  a  form  of  chronic  inflammation,  while  the  granulations  are  cither  the 
result  of  a  hypertrophy  of  the  air-cells,  (M.  Andral's  opinion,)  or  a  morbid  con- 
dition of  the  blood-vessels  which  ramify  around  the  same  cells  (M.  Lombard's 
opinion). — (M.  L.) 

i  The  experience  of  M.  Louis  has  led  him  to  an  opposite  conclusion  respec- 
ting the  relative  frequency  of  tubercles  in  the  two  lungs.  The  following  facts 
stated  by  him  tend  strongly  to  confirm  this  opinion  ;  the  only  question  is,  wheth- 
er his  cases  (123)  have  been  sufficiently  numerous  to  justify  our  adoption  of  the 
results  furnished  by  them  as  applicable  generally  to  the  disease.  Of  thirty-eight 
instances  in  which  he  found  one  upper  lobe  wholly  disorganized,  twenty-eight 
were  on  the  left  side ;  of  eight  cases  of  perforation,  seven  were  on  the  left 
side  ;  and  of  the  seven  cases  in  which  the  tubercles  were  confined  to  one  lung, 
five'  were  on  the  left  side.  (Op.  Cit.  p.  7,  8,  9.)  These  facts  are  very  strongly  in 
favor  of  his  opinion,  and  are  confirmed  by  the  observations  of  many  preceding 
writers.  Stark  says,  "  the  lungs  of  the  left  side  are  more  commonly  affected 
than  those  of  the  right;"  and  Dr.  Carmichael  Smyth,  in  his  remarks  on  this 
passage,  (Op.  Cit.  p.  393,)  says,  "  that  the  left  side  of  the  chest  is  more  fre- 
quently affected  by  disease  than  the  right,  is  a  fact  for  which  it  may  be  diffi- 
cult to  assign  a  reason,  but  that  the  observation  is  strictly  true,  any  one  may  be 
convinced,  who  will  take  the  trouble  (which  I  have  done)  of  comparing  witii 
that  view,  the  numerous  cases  of  pulmonary  phthisis  related  by  Bonetus,  Mor- 
gagni,  and  others. —  Transl. 

t  The  large  tuberculous  excavations  of  the  upper  lobe  arc  found  nearer  the 
posterior  than  the  anterior  parts  of  the  lungs,  according  to  the  original  state- 
ment of  Stark,  (Op.  Cit.  p;  369,)  and  the  later  authority  of  Louis,  (Op.  Cit.  p.  13.) 
Transl. 

§  This  I  suspect  was  Laennec's  own  case.  See  the  memoir  of  his  life  pre- 
fixed to  this  work. — Transl. 


PHTHISIS    PULMONALIS. 


301 


other  disease.  It  is  much  more  common,  however,  to  find  one 
single  excavation,  and  several  crude  tubercles,  in  a  pretty  ad- 
vanced state,  in  the  summit  of  the  lungs  ;  and  the  remainder  of 
these  organs,  although  still  crepitous,  and  in  other  respects 
sound,  crowded  with  innumerable  tubercles,  of  the  miliary  kind, 
extremely  small,  semi-transparent,  and  hardly  any  of  them  with 
the  yellow  speck  in  the  centre.  It  is  evident  that  these  miliary 
tubercles  are  productions  of  a  much  later  date  than  those  which 
had  given  rise  to  the  excavations.  As  well  from  the  result  of  my 
dissections,  as  from  observation  of  the  sick,  I  am  well  assured 
that  this  secondary  crop  of  tubercles  appears  about  the  time 
when  the  first  set  begin  to  be  softened.  Very  commonly  we 
observe  in  the  same  lung  evident  marks  of  two  or  three  succes- 
sive eruptions  of  tubercles.  Almost  always,  in  these  cases,  we 
find  that  the  most  ancient  of  those  which  occupy  the  summit  of 
the  lung,  have  already  reached  the  stage  of  excavation ;  that  the 
second  crop,  situated  around  and  rather  below  these,  has  al- 
ready become  yellow,  or  at  least  the  greater  part  of  them,  but 
are  still  of  no  great  size ;  that  the  third  eruption  composed  of 
crude  miliary  tubercles,  with  some  yellow  points  in  their  centre, 
is  situated  still  lower ;  and,  finally,  that  the  basis  and  inferior 
edge  of  the  lung  exhibit  the  most  recent  formation  of  all,  con- 
sisting of  miliary  tubercles  quite  transparent.  Some  of  this  last 
variety  are  also  found  here  and  there,  in  the  intervals  between 
the  zones  containing  the  other  formations.  The  varieties  of  the 
tuberculous  infiltration  which  1  have  denominated  grey  and  ge- 
latinous, are  almost  always  of  secondary  formation :  and  in  most 
cases  take  place  only  subsequently  to  a  secondary  eruption  of 
miliary  tubercles.  Exceptions  to  the  order  of  development  just 
described  are  by  no  means  common.  It  is  extremely  rare  for 
excavations  to  be  first  developed  in  the  middle  or  base  of  the 
lungs :  it  is  less  unusual  to  find  the  left  lung  more  affected  than 
the  right ;  it  is  excessively  rare  to  find  the  first  eruption  so  very 
numerous  as  to  prove  fatal.*     In  cases  of  this  kind  the  patient 

*  Cases  of  this  sort  merit  the  strict  attention  of  practitioners,  and  it  is  impor- 
tant that  they  should  be  familiar  with  them,  for  they  are  not  attended  by  the 
greater  part  of  the  symptoms  which  commonly  characterize  pulmonary  phthisis. 
Thus  there  is  only  a  cough  which  appears  too  slight  to  demand  serious  attention, 
and  which  is  regarded  either  as  nervous,  or  the  result  of  a  slight  but  obstinate 
irritation  of  the  larynx  or  trachea  :  there  is  no  pain  in  the  chest,  the  voice  is 
free,  and  the  patient  when  in  a  state  of  repose,  suffers  very  little  dyspnoea. 
This  exhibits  itself,  however,  as  soon  as  he  begins  to  move  :  plunging  the  whole 
body  into  water  may  also  bring  it  on  in  a  remarkable  manner.  On  the  other 
hand,  percussion  and  auscultation  give  only  negative  signs  ;  the  thoracic  parietes 
everywhere  yield  the  normal  sound,  and  the  natural  murmur  of  respiration  is 
heard  in  every  portion  of  the  lungs,  yet  the  patient  is  subject  to  a  constant 
febrile  excitement,  which  every  evening  and  night  shows  a  marked  exacerba- 
tion ;  he  loses  his  strength,  without,  at  the  same  time,  becoming  rapidly  emaci- 
ated, which  maybe  accounted  for  by  the  fact  that  many  patients,  in  spite  of 


302  PHTHISIS    PULMONALIS. 

falls  a  victim  to  the  attendant  fever,  without  ever  exhibiting 
very  considerable  or  sometimes  even  perceptible  emaciation  ;  and 
on  opening  the  body  we  find  a  great  number  of  very  large  crude 
yellow  tubercles,  more  or  less  softened,  and  without  any  admix- 
ture of  the  miliary  variety.  These  secondary  eruptions  of  tu- 
bercles are  not  confined  to  the  lungs  ;  at  the  same  period  of  the 
softening  of  the  first  crop  in  the  lungs,  they  make  their  appear- 
ance in  many  other  organs.  In  fact  it  is  a  rare  case,  in  phthisical 
subjects,  to  find  these  bodies  only  in  the  lungs ;  almost  always 
they  exist,  at  the  same  time,  in  the  coats  of  the  intestines,  where 
they  give  rise  to  ulcers,  which,  in  their  turn,  become  the  cause 
of  the  colliquative  diarrhoea  which  so  often  accompanies  phthi- 
sis. There  is,  perhaps,  no  organ  safe  from  the  attack  of  tuber- 
cles, and  wherein  we  do  not,  occasionally,  discover  them  in  our 
examination  of  phthisical  subjects.*     The  following  are  the  parts 

their  fever,  retain  their  appetite  and  eat  and  digest  their  food  without  trouble. 
With  some  of  them  the  feeling  of  hunger  is  even  very  strong,  and  they  are  not 
satisfied  except  by  a  full  meal.  I  recently  saw  a  young  person  with  chlorosis, 
in  whom  pulmonary  phthisis  assumed  the  form  I  have  described  ;  but  in  whom 
I  was  satisfied  of  the  existence  of  tubercles,  and  by  the  aid  of  auscultation  I 
was  able  to  discover  in  which  part  of  the  lungs  they  were  developed  in  the 
greatest  number.  Beneath  the  spine  of  the  right  scapula  the  sound  or  expiration 
was  much  more  evident  and  stronger  than  that  of  inspiration  :  it  resembled  a 
kind  of  blowing  murmur,  and  became  daily  more  and  more*  distinct. 

I  have  seen  other  patients  in  whom  the  rapid  development  of  pulmonary 
tubercles  caused  a  very  considerable  dyspnoea,  similar  to  that  which  commonly 
attends  organic  affections  of  the  heart :  this  dyspnoea  was  the  predominant 
symptom  with  them,  and  its  increased  severity  hastened  their  death.  In  such 
cases  the  parenchyma  of  both  lungs  is  found  completely  studded  with  tubercles, 
one  of  these  bodies  seeming  to  occupy  the  place  of  each  air-vesicle  :  we  thus 
perceive  how  numerous  are  the  obstacles  at  every  point  of  the  lung,  which 
oppose  the  accomplishment  of  sanguification  ;  and  this  explains  the  intensity  of 
the  dyspnoea.  On  the  contrary,  in  the  form  of  phthisis  which  I  have  described 
in  the  preceding  paragraph,  the  anatomical  lesion  is  not  the  same;  tuberculous 
masses  are  formed  near  the  top  of  the  lungs,  the  remainder  of  these  organs 
remains  sound  and  permeable  to  the  air  :  the  dyspnoea  is  thus  much  less  distinct, 
and  the  febrile  movement  predominates  over  all  the  local  symptoms. — Andral. 

*  The  simultaneous  existence  of  tubercles  in  different  organs  is  seen  much 
oftenerin  infancy  than  at  any  other  period  of  life.  In  a  great  number  of  bodies 
of  adults,  the  lungs  alone  contain  marks  of  these  accidental  productions.  In 
others  they  are  found  at  the  same  time  in  the  coats  of  the  intestines,  the  mu- 
cous membrane  of  which  they  often  raise ;  the  other  organs  are  mare  often  ex- 
empt from  them.  In  children,  on  the  contrary,  nothing  is  more  common  than 
to  find  tubercles  developed  at  the  same  time  in  a  great  number  of  organs.  In 
children,  a  tuberculous  degeneration  of  the  lymphatic  glands  appears  to  be  a 
very  common  disease'.  There  are  orgajis,  again,  in  which  the  formation  of 
tubercles  is  rare  in  the  adult,  and  more  common  in  children.  The  brain  is  such 
an  organ.  Modern  researches  have  discovered  that  many  cerebral  affections, 
both  acute  and  chronic,  in  children,  depend  on  the  presence  of  tubercles  in  the 
brain  or  in  the  membranes  by  which  it  is  enveloped.  A  very  remarkable  cir- 
cumstance attending  encephalic  tubercles  is,  that  they  are  developed  and  exist 
for  a  considerable  time  without  betraying  themselves  by  any  symptoms  :  then 
comes  on  one  of  those  acute  diseases  known  by  the  name  of  acute  meningitis, 
hydrocephalus,  &c.  and  the  children  die.  On  opening  their  bodies  we  com- 
monly find  either  in  the  membranes  or  the  substance  of  the  brain,  tuberculous 
deposits,  around  which  inflammation   exists.     Finally,  it   is  not   only  in   the 


PHTHISIS    PULMONALIS. 


303 


in  which  I  have  met  with  these  degenerations,  and  I  enumerate 
them  in  the  order  of  their  frequency  :  the  bronchial,  the  medias- 
tinal, the  cervical,  and  the  mesenteric  glands  ;*  the  other 
glands  throughout  the  body  :  the  liver — in  which  they  attain  a 
large  size,  but  come  rarely  to  maturation ;  the  prostate — in 
which  they  are  often  found  completely  softened,  and  leave,  after 
their  evacuation  by  the  urethra,  cavities  of  different  sizes  ;f  the 
surface  of  the  peritoneum  and  pleura,  (or  in  the  false  membranes 
investing  these,)  in  which  situations  they  are  found  small  and 
very  numerous,  usually  in  their  first  stage,  and  occasion  death 
by  dropsy  before  they  can  reach  the  period  of  softening ;  the 
epididymis,  the  vasa  deferentia,  the  testicle,  spleen,  heart,  uterus, 
the  brain  and  cerebellum,  the  bodies  of  the  cranial  bones,  the 
substance  of  the  vertebrae,  or  the  point  of  union  between  these 
and  the  ligaments,  the  ribs,  and  lastly,  tumors  of  the  kind  usu- 
ally denominated  schirrus  or  cancer,  in  which  the  tuberculous 
matter  is  either  intimately  combined  with,  or  separated  in  dis- 
tinct patches  from,  the  other  kinds  of  morbid  substance  existing 
in  these.J  Tubercles  are  found  more  rarely  in  the  muscles  of  vo- 
luntary motion  than  in  any  other  part.  The  most  remarkable 
case  of  this  sort  I  have  met  with,  was  that  of  a  consumptive  pa- 
tient who  had  tubercles  in  almost  every  situation  mentioned 
above,  and  who  had,  besides,  the  ureters  so  much  dilated  as  to 
receive  the  thumb,  and  their  internal  coat  converted  into  an  ad- 
hesive layer  of  tuberculous  matter.      In  this  person  the  lower 

brain  that  tubercles  may  be  thus  latent :  the  same  happens  in  all  the  organs :  in 
children  especially,  they  are  found  in  many  parts  where  no  symptom  gives  any 
cause  to  suspect  their  existence.  The  lung  itself  does  not  escape  this  law:  in 
almost  every  case  before  the  moment  arrives  when  the  symptoms  caused  by  pulmo- 
nary tubercles  have  become  permanently  established,  we  see  the  patients  enjoying 
long  intervals  free  from  cough  and  all  other  prominent  indications  of  pectoral  dis- 
ease. At  the  most  they  have  a  slight  dyspnoea  which  they  are  themselves  hardly 
sensible  of,  and  a  great  liability  to  take  cold,  which  the  oftener  it  is  repeated,  the 
more  difficult  it  is  to  get  rid  of  entirely,  till  at  last  comes  on  one  that  proves  fatal. 

M.  Louis  has  found  from  his  observations,  that  when  tubercles  in  an  adult 
are  formed  in  any  other  organ  than  the  lung,  they  exist  in  that  organ  also. 
This  kind  of  pathological  law  seems  to  me  very  true,  and  my  own  researches 
daily  confirm  it :  but  it  is  remarkable  that  the  rule  does  not  hold  in  infancy.  In 
children  it  is  less  uncommon  than  it  is  in  adults,  to  find  tubercles  in  the  various 
organs  of  the  body,  whilst  the  lungs  may  be  entirely  exempt  from  them. — 
Andral. 

*  M.  Louis  found  the  mesenteric  glands  more  frequently  affected  than  any 
others,  viz.  in  one  fourth  of  the  cases.  lie  also  found  the  kidneys  as  frequently 
affected  as  the  spleen,  viz.  in  one-sixth  of  the  cases. —  Transl. 

1 1  have  frequently  found  these  in  cases  where  no  symptoms  of  them  had  ex- 
isted during  life. — Author. 

X  It  must  be  remarked  that  while  consumptive  persons  have  so  often  tubercles 
in  the  intestines,  the  stomach  is  rarely  the  seat  of  them.  We  must  be  careful 
not  to  mistake  for  real  tubercles  those  very  common  granulations' which  in 
consumptive  subjects  project  above  the  surface  of  the  mucous  membrane  of  the 
intestines,  and  which  arc  nothing  but  follicles  more  developed  and  more  prom- 
inent than  common. — Andral. 


304  PHTHISIS    PULMONALIS. 

extremity  of  one  of  the  sterno-mastoid  muscles  was  converted 
into  tuberculous  matter,  firm  and  consistent ;  but  the  muscular 
structure  was  still  preserved  in  the  parts  most  altered.  In  those 
least  altered,  and  which  passed  by  insensible  gradation  into  the 
sound  portion,  the  tuberculous  matter  was  in  its  early  stage,  grey 
and  semi-transparent.  I  had  particularly  attended  to  this  man's 
case  ;  he  never  complained  of  pain  in  the  neck,  but  merely  of 
some  difficulty  in  moving  it.  At  the  same  time  the  cervical 
lymphatic  glands  were  full  of  tubercles,  and  much  enlarged. 
Sometimes,  but  very  rarely,  the  production  of  tubercles  begins 
in  the  parts  just  mentioned,  especially  in  the  mucous  membrane 
of  the  intestines  and  in  the  lymphatic  glands,  and  their  appear- 
ance in  the  lungs  is  the  result  of  a  secondary  formation.* 

Organic  changes  which  usually  attend  phthisis. — The  greater 
number  of  phthisical  subjects,  before  death,  attain  that  extreme 
degree  of  emaciation  from  which  the  Greeks  derived  the  name  of 
the  disease.  This  emaciation  is  strongly  marked  in  the  adipose 
cellular  membrane  and  muscles,  but  not  at  all  in  the  internal  or- 
gans.    The  intestines  may  appear  contracted,  but  this  is  chiefly 

*  The  opinion  of  Laennec  on  the  relative  frequency  of  tubercles  in  other  or- 
gans besides  the  lungs,  is  confirmed,  with  some  little  variation,  by  the  resear- 
ches of  Louis  and  Lombard.  The  following  is  the  order  of  frequency  observed 
by  Louis  in  the  123  cases  of  phthisis  recorded  in  his  work  :  the  small  intestines 
one-third;  mesenteric  glands  one-fourth;  large  intestines  one-ninth;  cervical 
glands  one-tenth  ;  lumbar  glands  one-fourteenth ;  prostate  one-fifteenth  ;  spleen 
one-sixteenth  ;  ovaries  one-twentieth  ;  kidneys  one-fortieth.  He  only  found 
tubercles  once  in  the  brain,  cerebellum,  spinal  marrow,  and  uterus  ;  and  does 
not  notice  their  occurrence  in  the  liver,  testicles,  bones,  muscles,  sub-serous  cel- 
lular tissue,  &c.  Only  once  did  he  find  tubercles  in  false  membranes  on  the 
pleura,  and  only  thrice  in  those  of  the  peritoneum.  In  one  case  only  out  of  358 
tuberculous  subjects,  did  he  meet  with  tubercles  in  various  organs,  while  there 
was  none  in  the  lungs.     (Rev.  Med.  Sept.  1825.) 

Lombard,  in  100  adult  subjects,  gives  the  following  as  the  proportional  fre- 
quency of  the  tuberculated  organs  :  intestines,  26  ;  mesenteric  glands,  1!' ;  bron- 
chial glands,  9;  cervical  glands,  7  ;  spleen,  6  ;  lumbar  glands,  sab-peritoneal 
cellular  tissue,  4  ;  axillary  glands,  anterior  mediastinum,  3  ;  sub-arachnoid  cellu- 
lar tissue,  spinal  marrow,  false  membranes  of  the  pleura  and  peritoneum,  inter- 
costal muscles,  ovaries,  2 ;  gall-bladder,  liver,  posterior  mediastinum,  pleura, 
vertebra?,  ribs,  omentum,  uterus,  prostate,  bladder,  brain  and  cerebellum,  me- 
dulla oblongata,  kidneys,  vesiculoe  seminales,  1.  It  is,  however,  worthy  of  re- 
mark that  the  same  number  of  infant  subjects  gave  proportions  considerably 
different,  viz.  bronchial  glands,  87  ;  lungs,  73;  mesenteric  glands,  31  ;  spleen, 
25  ;  kidneys,  11  ;  intestines,  nervous  centres,  9  ;  cervical  glands.  7  ;  meninges, 
6;  pancreas,  gastro-hepatic  glands,  sub-peritoneal  cellular  tissue,  5 ;  spleen, 
4  ;  (?)  inguinal  glands,  3  ;  sub-pleural  cellular  tissue,  2  ;  lumbar  glands,  bladder, 
omentum,  gall-bladder,  false  membranes  of  the  pleura,  1. — (.11.  L.) 

M.  Louis  says,  that  with  one  single  exception,  he  never  found  tubercles  in 
any  other  organ  without  their  existing  in  the  lungs  at  the  same  time,  insomuch 
that  he  seems  to  consider  their  presence  in  the  lungs  as  essential  to  their  devel- 
opment in  other  parts.  This  view  of  the  subject  is  strengthened,  he  think*,  by 
the  fact,  that  (with  a  single  exception)  he  always  found  the  tuberculous  matter 
much  more  advanced  in  the  lungs  than  in  the  cither  parts,  and  also  that  the  tu- 
bercles in  all  the  other  parts  were  always  in  the  same  degree  of  development. 
In  the  single  case  above  alluded  to,  he  found  tuberculous  matter  in  the  < 
teric  glands  when  none  existed  in  the  lungs.     (Op.  Cit.  p.  179.)— Trans! 


PHTHISIS     PULMONALE. 


305 


owing  to  their  containing  but  little  air  *  The  brain,  nerve,  ge- 
nital organs,  spleen,  pancreas  and  other  glands,  present  no  marks 
of  emaciation.f  The  blood-vessels  appear  commonly  small ;  but 
this,  no  doubt,  is  owing  to  their  having  been  a  long  time  accus- 
tomed to  contain  only  a  small  quantity  of  fluid,  in  consequence 
of  the  copious  evacuations  and  the  low  regimen  to  which  the  pa- 
tients are  usually  subjected.  The  bones  lose  nothing  in  point  of 
length,  but  I  have  frequently  thought  that  their  diameter  was 
lessened  in  cases  of  protracted  marasmus.  They  become  certainly 
of  less  specific  gravity ;  and  this,  no  doubt,  is  true  of  all  the 
other  organs  ;  although  the  effect  is  produced  in  a  variable  man- 
ner ;  since  we  find,  that,  of  two  patients  arrived  at  the  same  de- 
gree of  emaciation,  the  one,  with  broad  shoulders  and  tall,  shall 
sometimes  be  much  lighter  than  another  of  a  feebler  constitu- 
tion and  smaller  stature.  The  chest  of  consumptive  patients  is 
usually  narrow  and  sometimes  evidently  contracted.  This  con- 
traction had  obtained  the  notice  of  Bayle,  but  he  did  not  inves- 
tigate its  causes.  It  appears  to  me  to  depend  on  one  or  other  of 
the  two  following  causes: — 1.  on  the  pleurisies  to  which  phthi- 
sical patients  are  extremely  subject,  both  before  and  during  the 
course  of  their  disease,  and  which,  as  we  shall  see  hereafter,  al- 
ways give  rise  to  a  contraction  of  the  chest  when  they  terminate 
favorably ;  or, — 2.  to  the  attempts  made  by  nature  to  cure 
phthisis,  which,  as  we  shall  find  presently,  likewise  occasion  a 
similar  result. J     The  serous  membranes  and  the  skin  are  com- 

*  The  parietes  of  the  stomach,  especially  in  the  part  near  the  spleen,  are  fre- 
quently liable  in  consumptive  persons  to  grow  thin.  This  alteration  is  more 
especially  noticed  in  the  mucous  membrane,  which  becomes  soft  at  the  same 
time,  and  in  the  other  coats.  The  mucous  membrane  in  particular,  exhibits  com- 
monly but  a  few  pale  and  slender  fibres  :  it  is  evident  that  this  membrane  is  in 
a  state  of  atrophy.  The  sub-mucous  cellular  tissue,  on  the  contrary,  preserves 
its  normal  aspect,  and  very  often  it  is  found  bare  toward  the  great  extremity  of 
the  stomach,  merely  covered  here  and  there  with  some  remains  of  the  mucous 
membrane.  It  is  at  least  very  doubtful  whether  the  thinness  and  softening  of 
this  last  membrane,  is  in  such  cases  the  result  of  inflammation.  It  is  a  peculiar 
alteration  of  nutrition,  similar  to  that,  for  example,  which  in  consumptive  per- 
sons, causes  a  diminution  in  thickness  of  the  sclerotic  coat  of  the  eye, 
which  thus  becomes  semi-transparent  and  bluish.  At  the  same  time  that  the 
coats  of  the  stomach  become  thin,  they  distend  more  easily,  without  returning 
so  readily  to  their  normal  limits,  and  this  without  doubt,  is  the  reason  why  the 
stomachs  of  many  consumptive  subjects  are  found  so  remarkably  large  after 
death. — .indral. 

t  The  fatty  infiltration  of  the  liver  which  has  been  noticed  in  this  organ,  is 
an  alteration  found  almost  exclusively  in  individuals  whose  lungs  contain  tuber- 
nd  it  is  remarkable  that  with  these  patients,  it  is  more  common  in 
women  than  in  men.  What  is  then  the  singular  relation  which  connects  the 
production  of  tuberculous  matter  in  the  lungs  with  the  deposition  of  fatty  mat- 
ter in  the  liver  : — Andral. 

X  This  cause  of  the  contraction  of  the  chest  in  phthisical  subjects  cannot  be 
very  common,  for  it  is  not  common  to  observe  in  these  individuals,  those  abun- 
dant pleuritic  effusions,  which  after  absorption  cause  a  depression  of  the  thoracic 
parietes.      The  cellular  adhesions,   which   at   an  advanced  stage   of  phthisis 

39 


306  PHTHISIS     PULMONALIS. 

monly  very  pallid  and  bloodless  in  phthisical  subjects.  The 
muscles,  on  the  contrary,  particularly  the  heart,  are  usually 
of  a  bright  red.  The  latter  organ  is  moreover  always  remark- 
able on  account  of  its  smallness  and  firmness  :  may  it  be  affected 
by  the  general  emaciation  ?  The  intestines  sometimes  exhibit 
ulcers,  which  do  not  seem  owing  to  the  development  and  soften- 
ing of  tubercles  situated  in  their  membranes ;  but  those  arising 
from  this  latter  cause  are  much  more  common.  Ulcers  of  the 
kind  last  mentioned,  are  characterized  by  the  development  of 
small  miliary  tubercles,  or  of  tubercles  of  the  size  of  hempseed 
at  most,  in  the  mucous  or  muscular  tunic,  and  sometimes  imme- 
diately beneath  the  peritoneum.  They  occur  most  frequently 
in  the  small  intestine,  and  chiefly  near  its  termination.  They 
gradually  corrode  the  intestinal  tunics,  in  proceeding  from  with- 
in outwards,  and  are  very  frequently  found  resting  on  the  perito- 
neum only.  Perforation  of  this  tunic,  is,  nevertheless,  uncom- 
mon.* When  it  takes  place,  the  effusion  of  the  intestinal  matters 
into  the  peritoneum  usually  produces  an  acute  inflammation 
of  this  membrane  accompanied  by  tympanites.  However,  when 
the  perforation   is  small,  it   is  frequently  obliterated   by  the  adhe- 

constantly  unite  the  costal  and  pulmonary  pleura,  are  produced  insensibly, 
and  they  do  not  follow  the  disappearance  of  an  effusion  which  has  been  suffi- 
ciently large  to  be  discovered  by  auscultation  or  percussion.  The  observation  of 
Laennec  still  appears  to  me  quite  correct.  I  agree  with  him  that  in  fact  the 
chest  contracts  in  a  great  number  of  phthisical  subjects,  but  this  contraction  is 
more  common  than  it  would  be  if  it  depended  solely  on  the  two  causes  pointed  out 
by  Laennec.  It  may  be  partial,  and  is  then  observed  principally  in  the  subcla- 
vian regions  :  in  this  region  the  surface  of  the  chest  is  remarkably  flattened  and 
sinks  below  the  clavicles  into  a  hollow,  deeper  than  that  formed  by  any  other 
cause.  The  shrinking  of  the  sub-clavicular  regions  seems  to  me  to  depend  on  the 
loss  of  substance  which  occurs  to  the  lungs,  in  proportion  as  cavities  form  in 
the  upper  portions  :  this  of  necessity  causes  the  walls  of  the  chest  to  fall  in. 
There  are  other  cases  in  which  the  contraction  of  the  chest  may  be  general  . 
in  those  where  there  has  been  no  antecedent  pleuritic  effusion,  it  can  only  be 
explained  by  supposing  that  as  fast  as  the  tubercles  multiply,  the  tissue  of  the 
lungs  suffers  a  real  atrophy.  This  moreover  is  not  an  isolated  fact.  I  have 
shown  in  my  work  on  pathological  anatomy,  that  when  an  accidental  production 
is  developed,  it  often  happens  that  the  tissue  in  which  it  originates,  undergoes 
an  atrophy  which  may  increase  to  such  a  degree  as  nearly  to  extirpate  the 
tissue  ;  the  parenchyma  of  the  lungs  cannot  escape  this  law. — Andral. 

*  "  There  existed  (says  M.  Louis)  ulcers  in  the  small  intestines,  of  a  greater 
or  less  extent,  and  more  or  less  numerous,  in  five-sixths  of  the  cases.  They 
were  almost  as  frequent  in  the  large  intestines  ;  the  mucous  membrane  of  which, 
moreover,  although  often  red  and  thickened,  was  as  soft  as  mucus,  over  its 
whole  extent,  or  a  great  part  of  it,  in  one-half  the  cases.  Indeed,  I  found  this 
intestine  sound  over  its  whole  extent  in  three  cases  only."  (Op.  Cit.  p.  175.) 
Bayle  found  the  intestines  ulcerated  in  sixty-seven  cases  in  the  hundred.  An- 
dral  says,  that  among  all  the  phthisical  cases  which  came  into  M.  Lerminier's 
wards  for  five  years,  he  found  the  intestines  completely  sound  in  one-fifth  only. 
(Clin.  Med.  t.  hi.  p.  306.)  For  an  account  of  the  symptoms  resulting  from  per- 
foration of  the  intestines  in  acute  diseases,  see  M.  Louis's  memoir  on  this  subject 
in  his  "  Memoires  on  Recherches  Anatomico-pathologiques."  Paris,  1826,  p.  136. 
He  says  that  he  only  found  the  small  intestine  perforated  once  in  one  hundred 
and  fifty  cases  of  phthisis.—  Transl. 


PHTHISIS     PULMONALIS. 


307 


sion  of  the  edges  of  the  perforation  to  the  contiguous  portion  of 
peritoneum  covering  the  intestines  or  other  viscus,  by  means  of 
the  lymph  effused  in  the  first  moments  of  the  inflammation.  In 
this  case,  the  peritonitis  may  become  chronic ;  and  almost  always, 
when  this  happens,  a  very  plentiful  eruption  of  secondary  tuber- 
cles is  formed  in  the  false  membranes  produced  by  the  inflamma- 
tion. This  adhesion  of  the  perforated  intestine  presents  some- 
times a  remarkable  variety.  At  the  very  moment  when  the 
perforation  takes  place,  the  intestine  becomes  agglutinated  to  the. 
contiguous  peritoneum,  by  means  of  a  moderate  effusion  of  coa- 
gulable  lymph,  like  thickish  paste,  in  such  manner  that  neither 
effusion  of  the  intestinal  contents,  nor  peritonitis,  properly  so 
called,  takes  place.  It  is  no  doubt  true  that  the  exudation  just 
mentioned  must  be  considered  as  a  product  of  inflammation,  how- 
ever slight;  but  in  such  cases,  the  patient  during  life  complains 
of  no  pain,  and  after  death  the  peritoneum  is  not  found  red. 
This  species  of  sub-inflammation  and  the  secretion  resulting 
from  it,  seem  to  me  very  analogous  to  the  adhesive  inflammation  of 
wounds  which  unite  by  the  first  intention.  I  have  several  times 
observed  similar  adhesions  in  the  case  of  perforation  of  the  stom- 
ach and  intestines,  arising  from  other  causes,  particularly  cancers, 
gangrenous  eschars,  or  the  colorless  softening  lately  described  by 
Jaeger*  and  Cruveilhier.f 

The  mucous  membranes  are  generally  pale,  even  in  the  vici- 
nity of  the  ulcer,  except  in  the  cases  where  an  acute  fever  and 
prolonged  struggle  have  preceded  death,  and  given  rise  to  san- 
guineous congestion  in  different  parts.;);     It  is  a  common  opinion, 

*  Hufeland's  Journ.  May,  1811. 

t  Medccinc  eclair ee  par  VAnat.  pathol.     Paris,  1821. 

I  have  had  occasion  to  mark  the  following  case  :  a  consumptive  patient, 
who  for  some  time  had  shown  symptoms  of  chronic  peritonitis,  was  attacked  by 
a  fistula  in  the  navel,  and  through  this  accidental  opening,  there  passed  a  long 
round  worm.  I  was  then  convinced  that  the  intestine  was  also  perforated.  I 
thought  it  reasonable  to  suppose  that  before  it  became  perforated,  the  intestine 
had  contracted  adhesions  with  the  abdominal  coats  at  the  points  where  the  per- 
foration afterwards  took  place,  and  that  the  worm  might  thus  leave  the  intestine 
without  reaching  the  cavity  of  the  peritoneum.  Yet  this  was  not  the  fact;  in 
about  six  weeks  from  the  umbilical  perforation,  the  patient  died  :  there  was  no 
intestinal  adhesion  to  the  coats  of  the  abdomen  ;  the  peritoneum  showed  marks 
of  the  most  intense  chronic  inflammation,  with  a  purulent  collection  and  numerous 
false  membranes;  the  remains  of  worms  were  floating  in  the  pus. 

Thus,  in  this  almost  unique  case,  foreign  matter  had  issued  from  the  intestine 
and  touched  the  peritoneum  without  affecting  this  membrane  with  acute  inflam- 
mation ;  and,  contrary  to  the  ordinary  rule,  many  days  elapsed  before  death 
ensued  from  the  peritoneal  inflammation  which  arose  on  this  occasion. — Andral. 

i  This  statement  is  not  correct.  The  gastro-intestinal  mucous  membrane  is 
often  red  in  phthisical  subjects.  Andral  met  with  it  completely  pale  in  a  fifth 
part,  at  most,  of  his  phthisical  subjects.  (Clin.  Med.  t.  iii.  p.  306.)  Louis  found 
the  mucous  membrane  of  the  stomach  red.  softened,  thickened  in  one-twelfth 
of  his  cases;  that  of  the  small  intestines  reddened  totally  or  partially  in  one  in 
seven,  and  that  of  the   large  intestine?  in  one  of  four.     (Recherchcs,  pp.  81,   96, 


308  PHTHISIS    PULMONAL1S. 

strengthened  by  the  adoption  of  it  by  Bordeu,  that  phthisical  sub- 
jects are  particularly  liable  to  fistula  in  ano,  which  help  to  pro- 
tract the  termination  of  the  disease.  I  have  seldom  observed 
this  complication  ;  and  where  it  existed  it  has  appeared  to  exert 
no  influence  over  the  progress  of  the  case.*  The  liver  is  fre- 
quently large,  of  a  very  pale  yellow  color,  and  strongly  impreg- 
nated with  a  fatty  matter,  not  always  of  the  same  nature.f 
Sometimes  this  is  very  similar  to  fat :  but  at  other  times,  from  its 
appearance  and  consistence,  it  would  seem  analogous  to  those 
fatty  bodies,  long  confounded  under  the  general  name  of  adi- 
pocire,  and  which  M.  Chevreul  has  proved  to  be  of  different 
kinds.J  This  fatty  infiltration  of  the  liver  is  met  with  in  other 
chronic  diseases  as  well  as  phthisis,  and  I  have  even  seen  it  in 
cases  where  no  organic  affection  of  any  severity  co-existed.1^ 
Broussais  seems  to  think  that  this  condition  of  the  liver  is  sym- 
pathetic of  the  inflammation  of  the  duodenum.  I  would  here 
remark  that  I  have  seen  but  few  well-marked  instances  of  inflam- 
mation of  this  intestine ;  and  I  suspect  that  it  will  be  admitted 
te  be  extremely  rare,  by  all  anatomists  who  do  not  confound  the 
congestions  of  the  dead  body  with  inflammation.  Certain  it  is, 
that  I  have  frequently  found  the  duodenum  very  red  when  the 
liver  was  sound,  and  the  fatty  disorganization  of  the  latter  pre- 
sent, when  the  duodenum  was  very  pale.||     The  animal  fluids 

174.)  In  like  manner  the  mucous  membrane  of  the  trachea  is  very  often  both 
red  and  ulcerated ;  whilst  it  is  extremely  rare  to  find  that  of  the  bronchi  per- 
fectly pale  ;  in  this  last  case,  the  redness  is  generally  more  marked  in  the  vicini- 
ty of  (he  excavations,  no  doubt  in  consequence  of  the  irritation  produced  by 
the  continual  passage  of  the  softened  tuberculous  matter. — (M.  L.) 

*  Andral  says  he  only  met  with  one  instance  of  fistula  in  ano  in  about  eight 
hundred  cases  of  phthisis. —  Transl. 

t  M.  Louis  found  the  fatty  degeneration  of  the  liver  in  one  third  of  his 
cases  ;  and  exactly  the  same  proportion  is  recorded  by  M.  Andral,  as  the  result 
of  his  experience. —  Transl. 

%  Recherches  sur  les  Corps  gras,  §-c.     Paris,  1S23. 

§  Such  cases  are,  however,  rare.  Louis  noticed  the  fatty  liver  in  one  third  of 
his  phthisical  subjects,  while  he  only  met  with  it  twice  in  220  cases  of  other 
diseases.  M.  Louis  further  observed  this  morbid  state  of  the  liver  in  phthisical 
subjects  more  frequently  in  women  than  men  (in  the  proportion  of  four  to  one)  ; 
and  likewise  that  in  the  great  majority  of  such  cases  the  duodenum  was  sound, 
(Op.  Cit.  p.  115  et  seq.)— (M.  L.) 

||  For  a  most  accurate  and  minute  account  of  the  various  lesions  usually  ac- 
companying phthisis  pulmonalis,  I  refer  the  reader  to  the  three  classical  and 
truly  admirable  works  of  Bayle,  Andral,  and  Louis.  From  the  last  of  these, 
more  particularly  I  shall  here  extract  a  brief  notice  of  the  principal  of  these 
complications,  not  already  fully  noticed  in  the  text.  Inflammation  of  some 
portion  of  the  lungs  or  -pleura -was  found  in  one-tenth  of  the  cases;  but  we 
have  seen  in  a  former  note  that  this  proportion  is  not  greater  than  in  the  sub- 
jects dead  of  other  chronic  diseases.  The  mucous  membrane  of  the  trachea 
was  simply  red,  or  somewhat  thickened  and  softened  in  one-fifth;  and  ulcer- 
ated in  a  somewhat  less  proportion  than  one-third.  The  larynx  and  epiglottis 
were  ulcerated  in  one-fifth.  (Bayle  found  the  proportion  one-sixth  ;  and  An- 
dral found  the  larynx  affected  in  one  form  or  other  in  as  many  as  three-fourths.) 
The  pericardium  contained  a  "  notable"  quantity  of  serum  in   one-tenth.     (An- 


PHTHISIS    PULMONALIS. 


309 


seem  to  have  very  little  tendency  to  sceptical  decomposition  in 
phthisis  ;*  since  we  find  that  patients  in  this  disease,  are  much 
less  liable  to  gangrenous  eschars  on  the  back,  from  long  confine- 
ment, than  in  many  others,  and  that  their  bodies  after  death  are 
slow  in  running  into  putrefaction. 

I  shall  conclude  what  relates  to  the  morbid  anatomy  of  phthi- 
sis, by  the  examination  of  two  important  questions,  which  can 
only  be  resolved  by  means  of  the  data  supplied  by  anatomy. 
These  questions  are  the  following: — 1.  Are  tubercles  the  effect 
of  inflammation  ?  2.  Is  tuberculous  phthisis  susceptible  of  cure  ? 

dral  found  the  heart  diseased  or  altered  in  as  great  a  proportion  as  two-thirds.) 
The  stomach  was  much  distended  and  lower  than  natural  in  one-twelfth  ;  its 
mucous  membrane  was  softened  and  thinned,— or  very  red,  very  soft  and  thick- 
ened, in  one-fifth  ;  ulcerated  in  many  cases;  and  quite  sound  only  in  one-fifth. 
(Andral  says  in  two-fifths.)  The  peritoneum  contained  an  effusion  of  serum, 
from  one  to  six  pints,  in  one-fourth  ;  and  the  lateral  ventricles  were  distended 
by  a  "notable"  quantity  of  the  same,  in  three-fourths.  The  brain  was  more 
or  less  injected  in  one-seventh;  its  consistence  over  its  whole  mass  was  di- 
minished in  one-twentieth,  and  it  was  partially  softened  and  pulpy  in  the  same 
proportion.  Of  these  lesions  the  following  supervened  only  during  the  days  of 
life,  viz.  pneumony,  pleurisy,  softening  and  redness  of  the  large  curvature  of 
the  stomach,  pulpy  softening  of  the  mucous  membrane  of  the  colon,  peritonitis, 
arachnitis,  partial  softening  of  the  brain.  Others  existed  long,  some  even 
from  the  beginning  of  the  disease,  among  which  he  mentions  the  softening 
with  extenuation  of  the  mucous  membrane  of  the  stomach,  and  (sometimes) 
the  large  intestinal  ulcers.  Some  of  the  affections  just  enumerated,  are  consid- 
ered by  M.  Louis  as  peculiar  to  phthisis;  others  as  independent  of  it,  and  ex- 
isting in  many  other  chronic  diseases.  Of  the  first  kind,  he  reckons  the  follow- 
ing :  Ulcers  of  the  larynx,  and  more  particularly  of  the  trachea  and  epiglottis; 
ulcerations  of  the  intestines,  especially  of  the  smaller;  and  the  fatty  degenera- 
tion of  the  liver.  I  need  hardly  add  to  this  detail  of  the  various  and  numerous 
severe  affections  that  complicate  phthisis,  an  admonition  to  the  young  practitioner 
not  to  overlook  them  in  the  treatment  of  his  patients.  I  shall  probably  return  to 
this  subject  hereafter ;  but  I  cannot  resist  making  one  observation  relative  to  the 
complication  of  gastritis,  (both  acute  and  chronic,)  so  very  common  in  phthisis, 
and,  I  fear,  so  frequently  lost  sight  of  in  the  practice  of  many  practitioners.  An- 
dral says — "  The  frequency  of  gastritis  in  consumption  being  well  proved,  it  fol- 
lows as  a  necessary  consequence,  that  it  is  only  with  the  greatest  care  and  atten- 
tion that  we  can  venture  to  apply  substances  of  an  irritating  nature  to  the  mucous 
membrane  of  the  stomach.  Many  of  the  inflammatory  affections  of  this  organ  in 
phthisical  subjects  are  aggravated  and  rendered  permanent,  by  being  overlooked 
and  left  to  themselves,  merely  because  they  give  rise  to  no  very  prominent  symp- 
toms." (Clin.  Med.  torn.  iii.  p.  306.)  In  reference  to  this  complication,  I  would 
here  merely  allude  to  two  very  opposite  yet  very  common  plans  of  diet,  recom- 
mended in  this  disease, — one  almost  entirely  of  animal  food,  with  porter,  wine, 
<fcc.  and  the  other  of  milk  and  vegetable  and  farinaceous  matters.  In  such  a 
complication,  the  one  must  be  proper,  and.  if  it  do  not  tend  to  cure  the  disease, 
cannot  at  least  nccelerate  its  progress;  the  other  must  be  injurious  in  the  highest 
degree,  both  in  its  present  operation  and  future  consequences. —  Transl. 

In  1  he  consumptive  in  the  last  stage  of  the  disease,  the  blood  presents  an  aspect 
which  theory  would  not  have  prepared  us  to  expect.  On  venesection,  the  sur- 
face of  the  blood  is  found  covered  with  a  coat  of  the  same  consistence,  thick- 
ness, and  shape  as  in  the  pleurisy,  pneumonia,  or  acute  articular  rheumatism. 
The  riot  at  the  same  time  is  small  and  surrounded  by  a  plentiful  serosity. — 
.hiilriil. 


310  PHTHISIS    PULMONALIS. 


Sect.  II.     Examination  of  the  question  whether  or  not  tuber- 
cles are  the  consequence  of  inflammation. 

The  ancients  attributed  to  inflammation,  the  development  of 
all  the  accidental  productions  with  which  they  were  acquainted, 
and  which  they  generally  confounded  under  the  names  of  schir- 
rhus,  tumor,  tubercle  (Vxw<,  0^™)  ;  and  although  this  opin- 
ion had,  during  the  last  century,  been  rendered  doubtful  by  the 
progress  of  pathological  anatomy,  yet  Bayle  was  the  first  who  ex- 
ploded it  by  positive  facts.*  Broussais  who  about  the  same  period 
pursued  his  investigations  in  the  military  hospitals,  and  who  no 
doubt  was  ignorant  of  what  was  passing  at  Paris,  maintained  the 
ancient  opinion,  and  endeavored  to  support  it  by  facts  observed 
by  him.  More  recently  this  author  has  impugned  the  correct- 
ness of  Bayle's  opinion  ;f  and  he  still  continues  to  do  so,  more 
by  assertion  and  ratiocination,  however,  than  by  facts.  This  ques- 
tion appears  to  me  so  important,  that  I  shall  consider  it  in  refer- 
ence to  each  individual  texture  of  the  lungs  :  and  inquire  accord- 
ingly, to  which  of  the  inflammatory  diseases  of  the  chest — pneu- 
monia (acute  and  chronic),  catarrh,  pleurisy, — the  development 
of  tubercles  is  owing. 

Acute  pneumonia. — If  we  question  any  practitioner  ignorant 
of  morbid  anatomy,  but  who  is  a  man  of  observation  and  free 
from  prejudices,  I  have  no  doubt  that  he  will  give  it  as  his  opin- 
ion that  it  is  very  rare  to  see  the  symptoms  of  phthisis  super- 
vene to  acute  pneumonia.  Even  in  the  cases  where  this  sequence 
is  observed,  it  is  impossible  to  say  whether  the  pneumonia  has 
given  rise  to  the  tubercles,  or  whether  these,  acting  as  irritating 
bodies,  have  not  excited  the  pneumonia.  On  the  authority  of 
pathological  anatomy,  the  solution  of  the  question  is  much  more 
simple  ;  since  it  is  certain  that  we  very  rarely  find  tubercles  in 
the  lungs  of  those  who  have  died  of  pneumonia,  and  that  the 
greater  number  of  consumptive  subjects  exhibit  no  symptom  of 
this  disease  during  the  progress  of  their  fatal  malady,  nor  any 
trace  of  it  after  death.  Many  of  these  even,  have  never  been 
affected  with  it  durina;  the  whole  course  of  their  life.  If  tuber- 
cles  were  merely  a  product  or  termination  of  acute  pneumonia, 
we  should  be  able  to  ascertain  the  different  steps  of  the  tran- 
sition of  the  one  into  the  other,  in  the  same  manner  as  we 
are  able  to  describe  all  the  intermediate  degrees  between  the 
simple  inflammatory  engorgement  and  the  pulmonary  abscess. 
But  this  is  far  from  being  the  case.  It  is  said  that  chemical 
analysis  discovers  no  difference  between  the  softened  matter  of 

*  Recherches  sur  la  Phthisie  pulmonaire,  p.  136,  et  passim. 
t  Exam,  des  Doct.  Med.     Paris,  1816. 


PHTHISIS     PULMONALIS. 


311 


tubercles  and  true  pus  ;  in   like  manner  I  say  that  it  discovers 
none  between  the  albumen  of  the  egg  and  the  secretion  of  certain 
cancers;  but  these   facts  prove  the  imperfection  of  chemistry, 
rather  than  the   identity  of  the  matters  in  question.     In  almost 
all  their  physical  'characters,  tubercles  differ  from  pus  ;  and  in 
one  other  remarkable  particular  there  is  a   striking  diversity  be- 
tween them :  after  the    complete  evacuation   of  the  matter  of  a 
softened  tubercle,  it  is  never  renewed  ;  while  the  walls  of  an  ab- 
scess are  well  known  to  continue  to  secrete  pus,  after  it  has  been 
opened.     The  following  is  the   only  case  which  could  be  mis- 
taken, even  by  an  inaccurate  and   prejudiced  observer,  for  the 
termination  of  pneumonia  in  tuberculous  matter : — Three  or  four 
times  I  have  found  small  irregular  masses  of  yellow  tuberculous 
matter  in  the  midst  of  a  portion  of  hepatized  lung.     In  one  of 
these  cases,  two  tuberculous  masses  of  the  size  of  filberts,  existed 
in  the  centre  of  a  portion  of  lung  already  advanced  to  the  stage 
of  purulent  infiltration.     Even  in  this  case,  however,  the  tuber- 
cles  were  very  readily  distinguished  by  their  color,  which  was 
much  paler  than  that  of  the  surrounding  parts ;  and  indeed  it 
formed  a  marked  contrast  with  the  deeper  yellow,  verging  on  ash- 
grey  of  the  purulent  infiltration.     These  parts  differed  in  another 
respect  also ;  on  scraping  the  surface  of  the  tuberculous  mass,  no 
fluid  could  be  squeezed  out,  while  on  pressing  the  other,  a  bloody 
pus  was  collected  on  the  scalpel.     It  would  certainly  be  absurd  to 
infer  from  this  very  rare  case,  that  the  tuberculous  masses  were 
the  effect  and  termination  of  the  pulmonary  inflammation  ;    for 
independently  of  the  rarity  of  the  case  in   question,  compared 
with  the  frequency  of  hepatization,  on  the  one  hand,  and  of  tu- 
bercles on   the  other,  I  have  found  tubercles  of  exactly  the  same 
kind  in  lungs  which  were,  in   other  respects,   quite  sound.     It  is 
certainly  more  probable  that,  in  this  case,  the    tubercles  existed 
previously  to  the  pneumonia,   or  even   that  they  gave  rise  to  it, 
as  foreign  bodies  producing  irritation.     On  referring   to  facts,  it 
is  found  that  acute  pneumonia  and  tubercles  occasionally  co-exist ; 
but  this  co-existence  is  rare  when  we  take  into  account  the  great 
frequency  of  both  diseases.     In  nineteen-twentieths  of  the  cases 
of  this  complication,  the  tuberculous  affection  evidently  precedes  j 
and  we  may,  therefore,  infer  either  that  the  tubercles  are  the  oc- 
casional cause  of  the  pneumonia,  or  that  the  diseases,  although 
co-existing,  have  no  etiological   relation  to   each  other.     I  am 
willing   to  admit,  as  a  matter  of  no  evil  consequence  in  practice, 
and  of  no  importance  in  theory,  (although  it  is  supported  neither 
by  direct  experiment  nor  positive  observation,)  that,  in  the   small 
number  of  cases  where  phthisis  is  seen  to  arise  during   the  con- 
valescence from  acute  pneumonia,  the  inflammation  may  some- 
times accelerate  the  development  of  the  tubercles,  to  which  the 


312  PHTHISIS     PULMONALIS. 

patient  was  previously  disposed,  from  some  other  cause, — of  the 
nature  of  which  we  are  ignorant,  but  which  is  assuredly  different 
from  inflammation.  In  this  case,  although  the  inflammation 
cannot,  by  itself,  produce  tubercles,  it  may,  through  the  excess 
of  action  and  nutrition  wherewith  it  is  attended,  hasten  their  ap- 
pearance ;  in  the  same  way  (to  use  a  comparison,  which  is  per- 
haps not  so  foreign  to  the  process  as  it  may  seem  at  first  sight) 
as  a  soil  well  tilled  after  a  long  fallow,  or  left  fallow  after  several 
years'  culture,  will  cause  many  seeds  to  germinate  which  had 
lain  within  it,  in  a  state  of  inactivity,  for  several  years.* 

Chronic  pneumonia. — It  was  stated  in  a  former  chapter  how 
rare  true  chronic  pneumonia  is ;  and  we  have  seen  how  different 
the  appearance  and  physical  characters  of  this  affection  are  from 
those  of  tubercles.  It  is  evident  that  in  chronic  pneumonia  the 
inflammatory  engorgement  is  confined  to  the  air-cells,  which  are 
seen  closely  pressed  together,  like  the  eggs  of  certain  insects, 
without  any  intervening  space,  all  of  the  same  size,  and  of  a 
reddish,  greenish,  or  yellowish  color.  When  of  the  last-men- 
tioned color,  if  they  are  pricked  with  a  needle,  they  sometimes 
exude  a  drop  of  pus.  If  we  compare  this  lesion  with  miliary 
tubercles  of  the  smallest  size,  which  from  their  roundish  shape 
might  seem  also  to  be  formed  in  the  interior  of  an  air  cell,  we 
shall  find  an  immense  difference  between  them.  These  latter 
bodies,  as  we  have  already  stated,  are  either  diaphanous  or  quite 
transparent,  and  however  numerous  they  may  be,  are  always 
disseminated,  at  least  in  their  earliest  stage,  through  the  sound 
and  crepitating  lung :  they  grow  by  intus-susception,  and  do 
not  coalesce  until  they  have  lost  their  primitive  shape  and  color. 
If  we  submit  the  other  varieties  of  the  tuberculous  degeneration 
to  the  same  kind  of  comparison,  we  shall  find,  in  like  manner, 
that  there  exists  no  relation  whatever  between  them  and  chronic 
pneumonia.  M.  Broussais,  nevertheless,  who  seems  never  to 
have  met  with  the  true  chronic  pneumonia,  wishes  to  consider 
phthisis  as  such.  After  what  has  been  stated,  it  would  be  use- 
less to  discuss  the  question  anatomically.  The  single  fact  of  the 
existence  of  a  chronic  pneumonia,  very  different  from  the  tuber- 
culous affection,  both  in  its  anatomical  characters  and  its  symp- 
toms, is  sufficient,  in  my  opinion,  to  decide  the  question  in  the 
negative.f 

*  Laennec  thus  admits  that  acute  pneumonia  may  sometimes  expedite  the 
development  of  pulmonary  tubercles,  that  is,  be  the  occasional  cause  of  them  in 
a  predisposed  subject;  but  he  contends,  with  much  apparent  reason,  that  it  can- 
not be  the  proximate  cause  :  and  those  who  regard  tubercles  as  a  morbid  secre- 
tion always  preceded  by  an  inflammatory  or  congestive  process,  have  not  been 
able  to  go  farther  lhan  this.  (See  Andral  Clin.  Med.  t.  iii.  p.  56.  Lombard, 
Op.  Cit.  p.  30,  Ac.)— (M.  L.) 

t  The  distinction  which  Laennec  here  labors  to  establish  between  true  chronic 


PHTHISIS    PULMONALE.  ^ld 


Catarrh.— There  is  not  a  more  ancient  opinion  in  physic,  or 
one  that  has  been  longer  adopted  by  the  vulgar,  than  that  an 
ill-treated  or  neglected  cold  is  apt  to  degenerate  into  phthisis. 
This  old  notion  has  been  adopted  by  M.  Broussais,  with  no 
better  reason,  apparently,  than  that  which  influenced  its  early 
patrons— post  hoc,  ergo  propter  hoc.  We  shall  now  proceed  to 
examine  the  foundation  on  which  it  is  considered  to  rest.— It  is 
no  doubt  true,  that  in  most  phthisical  cases,  the  first  symptoms 
are  those  of  pulmonary  catarrh ;  but  it  is  equally  true,  that  we 
find  very  large  and  very  numerous  tubercles  in  subjects  who 
exhibit  no  signs  of  catarrh.  If  it  be  said  that  the  tubercles 
are  the  product  of  former  catarrhs,  I  reply,  that  they  exist  m 
persons  who  have  not  had  catarrh  for  years,  or  even,  as  far 
as  they  can  recollect,  at  all.  We  indeed  frequently  observe 
a  pulmonary  catarrh  (coming  on  suddenly  during  a  state 
apparently  of  perfect  health,  or  after  slight  indisposition, 
which  do  not  seem  at  all  to  affect  the  chest)  to  be  the  first  ob- 
vious symptom  of  a  tuberculous  phthisis:  this,  however,  is 
found  to  have  existed  long  in  a  latent  state ;  since  we  find,  on 
examining  the  chest  of  such  subjects,  all  the  physical  signs  of 
tubercles,  and  sometimes  even  of  tubercles  already  excavated. 
The  same  thing  is  also  very  common  in  those  irregular  cases  of 
phthisis,  of  which  the  first  and  chief  symptom  is  an  invincible 
diarrhoea.  On  the  other  hand,  thousands  of  persons  have  catarrh 
several  times  every  year,  and  yet  very  few  of  these  become 
phthisical.  We  even  very  frequently  meet  with  individuals  who 
take  cold  incessantly  from  the  slightest  changes  of  weather,  and 
in  whom  each  cold  is  merely  an  aggravation  and  manifestation  of 
an  habitual  latent  catarrh  under  which  they  labor,  as  I  stated 
on  a  former  occasion.  There  is  another  numerous  class  of  per- 
sons, who,  during  a  long  series  of  years,  are  affected  with,  a  pi- 
tuitous  or  mucous  catarrh,  with  copious  expectoration,  and  who, 
nevertheless,  frequently  reach  an  advanced  age  without  becom- 
ing phthisical.  The  inhabitants  of  our  coasts  are  much  more 
subject  to  catarrh  than  those  in  the  interior  ;  few  of  the  former 
being  without  some  sign  of  this  disease,  latent  or  manifest ;  and 
yet  consumption  is  much   rarer  in  the  former  situation  than  in 

'  pneumonia  and  the  grey  or  jelly-like  tuberculous  infiltration,  is  completely 
rejected  by  the  new  anatomical  school  of  which  Andral  and  Cruveilhier  may  be 
regarded  as  the  heads.  According  to  M.  Andral,  we  have  in  the  grey  infiltra- 
tion nothing  but  the  highest  degree  of  induration  of  the  air  cells  and  minute 
bronchi,  (Precis  d'An.  Path.  t.  ii.  p.  547,)  and  in  the  jelly-like  infiltration  a 
retion$ro  generis,  just  as  we  find  other  peculiar  kinds  in  the  system  (Diet, 
dc  Mid.  Art.  Phthisie,  t.  xvi.)  I  will  not  attempt  to  refute  these  propositions, 
although  they  appear  to  me  far  from  being  proved.  I  will  merely  make  the 
same  remark  in  reference  to  the  grey  infiltration,  which  I  made  respecting  the 
granulations  :  it  is  met  with,  in  many  other  organs  beside  the  lungs.— (M.  L.) 

40 


314  PHTHISIS    PULMONALIS. 

the  latter.*  I  am  far  from  wishing  to  infer  from  this  fact,  that 
pulmonary  catarrh  is  a  preservative  against  the  development  of 
tubercles,  but  I  think  I  may  conclude  that  it  is  not  the  cause 
of  these.  I  am  moreover  of  opinion,  that  every  practitioner 
who  shall  investigate  this  matter  attentively,  impartially,  and 
thoroughly,  will  admit,  that  if  we  sometimes  observe  phthisis 
occurring  in  subjects  very  liable  to  colds,  we  find  a  much  greater 
number  of  these  not  becoming  phthisical ;  and  that,  on  the  other 
hand,  we  meet  with  many  persons  whose  first  cold,  is  merely  the 
catarrh  that  accompanies  phthisis,  excited,  no  doubt,  by  the  pre- 
sence of  tubercles  in  the  lungs.  For  my  own  part,  the  result  of 
my  whole  medical  experience  leads  me  to  look  with  suspicion 
and  apprehension  on  the  first  cold,  if  it  shows  itself  after  the 
twentieth  and  before  the  sixtieth  year. 

I  would  here  return  to  the  consideration  of  the  question  in  an 
anatomical  point  of  view,  and  shall  repeat  the  argument  formerly 
used  in  regard  to  pneumonia.  To  prove  that  phthisis  is  an 
effect  and  termination  of  catarrh,  it  would  be  necessary  to  ex- 
hibit anatomically  the  marks  of  the  transition  of  the  one  into 
the  other.  But  this,  I  conceive,  is  not  only  impracticable,  but 
the  idea  almost  absurd,  inasmuch  as  we  know  that  catarrh  con- 
sists in  an  inflammation  of  the  mucous  membrane  of  the  bronchia, 
whilst  tubercles  are  accidental  productions,  that  is,  real  foreign 
bodies,  which  spring  up  in  the  substance  of  the  lungs,  and  may 
be  developed  in  any  other  texture  of  the  body  ;  whilst  nothing 
is  more  uncommon  than  to  meet  with  these  bodies  in  the  bron- 
chial membrane  itself,  even  when  the  lungs  are  completely  charged 
with  them.f  Substituting  hypothesis  for  fact,  we  may,  indeed, 
suppose,  from  their  roundish  form,  that  miliary  tubercles  origi- 
nate within  the  bronchial  cells,  and  are,  in  fact,  the  consequence 
of  the  inflammation  of  these.J     We  may  suppose,  in  like  manner, 

*  We  cannot  assent  implicitly  to  this  statement.  Sufficient  materials  whereon 
to  build  a  solid  judgment  do  not  yet  exist ;  nor  can  they  do  so,  until  the  neg- 
lected, but  most  important  subjects  of  medical  topography  and  medical  statistics 
are  much  more  cultivated  than  they  are  at  present.  As  far  as  regards  the  pre- 
valence of  different  diseases  in  different  places,  we  possess,  in  this  country,  the 
most  correct  and  ready  means  of  judging,  in  our  numerous  dispensaries  and  hos- 
pitals. All  that  is  wanting  is  co-operation  among  the  members  of  the  profession  ; 
and  I  have  long  thought  that  this  might  be  obtained  without  much  difficulty. 
In  respect  of  the  relative  prevalence  of  consumption  in  different  parts  of  this 
island,  we  have  some  valuable  documents  in  the  works  of  Haygarth,  Wolcombe, 
Southey,  Bateman,  &c.  &c. ;  but  none  of  sufficient  accuracy  to  enable  us  to 
confirm  or  confute  the  assertion  in  the  text :  my  own  experience,  however, 
leads  me  strongly  to  doubt  its  truth. —  Transl. 

t  I  do  not  think  the  argument  used  in  this  and  the  preceding  sentence  is^ 
sound.  There  can  be  little  doubt,  I  presume,  that  enlargement  and  disease  of 
the  mesenteric  glands  are  often  the  consequence  of  irritation  or  inflammation  of 
the  mucous  membrane  of  the  intestines,  when  we  can  trace  no  appearance  of 
tubercles  in  this. —  Transl. 

t  This  would  appear  to  be  the  opinion  of  Andral,  or,  at  least,  one  of  his 
opinions — for  he  seems  to  have  several.     See  Clin.  Med.  t.  iii.  p.  11. —  Transl. 


PHTHISIS    PULMONALIS. 


315 


from  some  similarity  in  the  color  and  other  physical  characters 
between  incipient  tubercles  and  the  pearly  sputa,  that  the  former 
are  composed  of  the  same  materials  as  the  latter,  only  more  con- 
densed. By  such  hypotheses  as  these,  we  may  demonstrate  what- 
ever we  please  to  those  who  will  receive  our  notions  without 
proof;  but  minds  of  a  more  philosophic  temper  will  hesitate 
before  they  pass  the  boundaries  of  observation  ;  and,  where  the 
question  is  one  of  facts,  will  admit  of  no  solution  that  is  founded 
merely  on  suppositions.  In  the  present  case,  anatomy  affords  us 
no  assistance.  From  the  exact  round  or  ovoid  shape  of  certain 
miliary  tubercles,  I  have  certainly  been  sometimes  disposed  to 
imagine  that  they  might  be  formed  in  the  air-cells  ;  but  I  have 
never  been  able  to  convince  myself  of  the  fact.  Besides,  if  such 
were  the  case,  it  would  scarcely  happen  that  some  of  these  granu- 
lations should  not  sometimes  be  dislodged  and  expectorated.  But 
this  has  never  been  observed.  On  the  other  hand,  this  suppo- 
sition is  rendered  extremely  improbable  by  the  very  irregular 
form  of  most  of  the  grey  miliary  tubercles,  and  by  their  inti- 
mate adherence  to  the  pulmonary  substance  ;  and  the  hypothesis 
becomes  altogether  idle  and  frivolous,  when  we  recollect  that  it 
is  still  a  matter  of  doubt  whether  the  pulmonary  tissue  is  in  fact 
composed  of  cells  or  of  a  simple  intertexture  of  vessels.*     It  has 

*  One  of  the  most  interesting  results  of  the  researches  of  Reisseisen  respect- 
ing the  structure  of  the  lungs,  has  been  the  discovery  of  the  manner  of  the 
termination  of  the  bronchi ;  he  has  shown  that  what  before  his  time  had  been 
considered  as  a  particular  tissue,  a  mass  of  cellules  or  vesicles  in  which  the  air 
passages  terminated,  is  nothing  less  than  the  termination  of  the  bronchi  them- 
selves. Most  anatomists  have  been  acquainted  with  the  work  of  Reisseisen 
through  the  medium  of  summaries  or  quotations.  Some  have  admitted,  others 
have  rejected  his  conclusions ;  but  very  few  of  them  have  attempted  to  verify 
them,  and  it  appears  by  what  has  been  published  since  his  time,  (1808  to  1822), 
that  no  one  has  obtained  results  sufficiently  evident  to  decide  the  question  ; 
on  the  contrary,  the  latest  anatomical  works  seem  to  consign  Reisseisen's  dis- 
covery to  oblivion. 

Doct.  Bazin  of  Basseneville,  having  designed  some  researches  respecting  the 
seat  of  certain  lesions  of  the  respiratory  apparatus,  thought  it  proper  to  begin 
by  studying  its  structure.  He  has  not  limited  his  inquiries  to  a  single  species 
of"  lung,  like  the  author  who  preceded  him,  but  has  studied  the  whole  series  of 
vertebrated  animals.  Several  fine  preparations  of  the  human  lungs  and  those 
of  other  mamnalia,  which  he  has  submitted  to  my  examination,  seem  to  prove 
that  the  pulmonary  cellules  or  vesciles  are  not  really  cellules  or  vesciles,  but 
the  extremities  of  the  last  divisions  of  the  bronchi. — Andral. 

All  that  Laennec  regarded  as  possible,  or  supposable,  is  admitted  as  positive 
by  those  who  regard  tubercles  as  a  species  of  pus.  M.  Majendie  was  the  first 
who  imagined  that  the  secretion  of  this  pus  took  place  in  the  pulmonary  cells, 
and  he  conceived  that  if  the  secreted  matter  did  not  exactly  fill  the  cellules,  it 
might  be  at  once  expectorated.  (Journ.  de  Physiol,  t.  i.  p.  82.)  M.  Cruveilhier 
went  further,  and  imagined  that  this  mode  of  formation  and  this  site  of  tuber- 
cles, might  explain  at  once  their  rounded  form  and  their  simultaneous  develop- 
ment in  many  parts  of  the  lungs.  (Med.  Pract.  iclairie.  p.  175.)  More  lately 
Andral,  considering  that  tubercles  are  not  found  exclusively  in  the  lungs,  be- 
lieves that  the  secretion  of  pulmonary  tubercles  may  take  place  indifferently 
either  on  the  free  surface  of  the  bronchi  or  in  the  cellular  tissue  which  unites 
together  the  various  parts  of  the  lungs.     (Clin.  Med.  t.  iii.  p.  28)     And,  finally, 


:M6  phthisis  pulmonalis. 

been  asserted  by  one  of  M.  Broussais's  disciples,  that  lie  could 
produce  tubercles  at  pleasure,  by  irritating  in  a  certain  manner 
the  bronchi  of  a  dog  ;  but  1  believe  that  the  thing  has  never  yet 
been  done,  nor  the  manner  of  doing  it  ever  explained.  It  can 
only  be  when  the  process  is  exhibited  to  us,  that  wc  can  ascer- 
tain whether  a  secretion  of  pus  may  not  have  been  mistaken  for 
tubercle.f 

Pleurisy. — Without  entering  upon  the  hypothesis  used  by  M. 
Broussais  in  his  attempts  to  explain  the  supposed  production  of 
phthisis  by  pleurisy*  I  shall  confine  myself,  in  this  place,  to  the 
examination  of  the  data  furnished  by  pathological  anatomy  to- 
wards the  solution  of  the  question.  In  a  case  of  severe  pleurisy, 
the  inflammatory  afflux  is  not  propagated  to  the  lung :  on  the 
contrary,  the  copious  secretion  of  scrum  which  takes  place  at  the 
very  beginning  of  the  disease  compresses  this  organ  against  the 
mediastinum,  and  thereby  diminishes  its  stock  of  blood  and  other 
juices.  It  ought  to  result  from  this,  that  if  (as  M.  Broussais 
maintains)  tubercles  are  produced  by  inflammation  and  irritation, 
pleurisy  should  seem  more  likely  to  prevent  than  facilitate  their 
formation  in  the  pulmonary  substance,  since  it  extinguishes  nearly 
all  their  vital  energy.  In  cases  of  empyema  of  more  than  a  year's 
standing,  we  constantly  find  the  substance  of  the  lung  sound, 
with  the  exception  of  its  being  compressed.  And  in  most  of  the 
cases  in  which  I  have  met  with  the  tubercles  co-existing  with  em- 
pyema, this  disease  has  been  the  consequence  either  of  perfora- 
tion of  the  pleura  by  a  softened  tubercle,  or  the  presence  of  a 
great  many  tubercles  immediately    beneath  this  membrane.     It 

M.  Lombard  regards  this  cellular  tissue  as  the  exclusive  site  of  the  tubercular 
secretion,  and  chiefly  on  this  consideration — that,  being  at  its  formation  a  fluid, 
the  tubercular  matter  must  be  immediately  expectorated  and  would  show  itself 
in  the  sputa,  if  deposited  in  the  bronchi.  (Essai  sur  les  Tuberc.  p.  22.) — (M.  L.) 
*  The  experiments  alluded  to  in  the  text  are  now  well  known,  being  the  in- 
jection of  mercury  into  the  air  passages,  whereby  tubercles  were  imagined  to  be 
developed  in  the  lungs.  But,  as  Laennec  supposed,  in  this  experiment,  pus  was 
mistaken  for  tuberculous  matter,  and  by  no  less  eminent  a  person  than  Profes- 
sor Cruveilhier.  "  I  injected,"  says  he,  "  through  an  opening  made  in  the  tra- 
chea of  a  dog,  two  ounces  of  mercury,  the  greater  portion  of  which  was  rejected 
by  coughing.  The  dog,  however,  became  apparently  phthisical,  and  died 
emaciated  at  the  end  of  a  month.  The  lungs  were  crammed  with  tubercles 
both  isolated  and  agglomerated,  having  all  the  character  of  miliary  tubercles." 
(Nouv.  Bib.  M6d.  Sept.  1826,  p.  391.)  M.  Andial  made  the  same  experiment 
conjointly  with  M.  Lombard,  but  he  reports  differently  of  the  results.  "  The 
mercury  contained  in  the  smaller  bronchi  was  enveloped  in  a  thick  layer  of 
puriform  mucus,  which  was  in  some  points  quite  liquid,  and  in  others  very 
like  the  false  membrane  of 'croup,  when  only  become  half-solid.  In  several 
places  the  bronchial  parietes  were  torn,  and  the  mercury  extravasated  in  the 
pulmonary  tissue  was  surrounded  by  purulent  matter  :  ice  observed  nothing  be- 
sides. (Precis.  d'Anat.  Path.  t.  ii.  p.  551.)  I  may  here  observe,  that  M.  Andral, 
who  maintained  the  primary  liquidity  of  tubercles  in  1826  (Clin.  Med.  t.  iii.  p. 
4,  et  seq.)  doubts  this  in  1830,  and  seems  disposed  to  think  that,  like  the  epider- 
mis, tubercles  may  be  secreted  in  a  solid  ionri.  (Precis.  d'Anat.  Path.  t.  i.  p. 
413.;— (M.  L.) 


PHTHISIS    PULMONALIS. 


317 


is  a  thing  of  every  day's  occurrence,  to  find  pleurisies,  either 
latent  or  manifest,  supervene  in  the  progress  of  phthisis  ;  and  in 
those  rare  cases  where  this  disease  seems  ushered  in  by  an  atten- 
dant pleurisy,  the  sthethoscope  enables  us  to  detect  in  many  of 
them,  the  presence  of  a  great  accumulation  of  tubercles  in  the 
upper  part  of  the  lungs,  or  even  of  some  already  softened  and 
excavated.  We  may,  therefore,  I  conceive,  rigorously  conclude, 
that  pleurisy  is  very  frequently  an  effect  of  the  presence  of  tu- 
bercles in  the  lungs  ;  and  that,  if  we  admit  that  it  is  sometimes 
a  cause  of  them,  we  can  neither  demonstrate  this,  nor  yet  be  cer- 
tainly convinced  of  it.# 

From  all  that  has  gone  before,  we  are  authorized  to  conclude, 
that  tubercles  are  not  the  product  of  inflammation  of  any  one  of 
the  constituent  textures  of  the  lungs.  On  the  contrary,  a  mul- 
titude of  facts  prove  that  the  development  of  the  tubercles  is  the 
result  of  a  general  condition  of  the  body ;  that  it  takes  place 
without  previous  inflammation ;  and  that,  when  inflammation 
coincides  with  tuberculous  affection,  it  is  most  frequently  pos- 
terior to  it  in  its  origin.  To  convince  ourselves  of  the  accuracy 
of  this  last  proposition,  we  need  only  examine  the  progress  of 
tubercles  in  scrophulous  glands.  We  frequently  find  these  to 
swell,  and  remain  for  a  long  time  in  this  state,  and  without  any 
redness  either  of  the  adjoining  skin  or  even  of  the  substance  of 
the  gland  itself.  It  is  frequently  even  several  years  before  any 
marks  of  inflammation  show  themselves  ;  but  when  this  occurs, 
it  seems  to  accelerate  the  softening  of  the  tuberculous  matter. 
Sometimes,  however,  not  only  the  softening  of  this  matter,  but 
even  the  perforation  of  the  skin  and  the  discharge  of  the  pus 
take  place  without  any  distinct  mark  of  inflammation.  When 
this  occurs,  it  has  its  site  evidently  in  the  parts  contiguous  to 
the  gland,  and  not  in  the  gland  itself.  Another  proof  of  the 
same  fact,  and  one  equally  strong,  is  supplied  by  the  existence 
of  those   secondary   eruptions  of   tubercles,  particularly  such  as 

*  For  some  strong  arguments  and  facts  against  the  doctrine  of  tubercles  being 
a  consequence  of  pleurisy,  pneumonia,  and  catarrh,  I  refer  the  reader  to  M. 
Louis's  Treatise,  p.  503.  et  seq.  He  says  that  of  eighty  phthisical  subjects,  into 
whose  previous  history  he  had  particularly  inquired,  only  seven  had  ever  been 
affected  with  pneumonia,  and  four  of  these  had  been  perfectly  free  from  any 
pectoral  affection  for  several  years  before  the  invasion  of  the  phthisis.  He  no- 
tices the  fact  formerly  stated  by  our  author,  of  tubercles  being  most  frequent  in 
the  upper  lobes,  while  pneumonia  most  commonly  occupies  the  lower.  He  adds 
that  pneumonia  rarely  affects  both  lungs,  while  phthisis  almost  always  does  so  ■ 
and  that  the  former  is  most  common  in  men,  while  the  latter  is  so  in  women. 
The  same  remarks,  he  says,  apply  to  pleurisy  and  catarrh,  with  this  addition 
that  in  cases  of  chronic  pleurisy,  he  has  found  as  many  tubercles  in  the  lunc  of 
the  sound  as  in  that  of  the  diseased  side.  Out  of  the  eighty  cases  of  phthisis 
above  alluded  to,  only  twenty-three  had  been  particularly  subject  to  catarrh  : 
and  out  of  one  hundred  and  forty-nine  cases  of  catarrh  "treated  by  him,  only 
fifty-two  occurred  in  women. —  Transl. 


318  PHTHISIS    PULMONALIS. 

affect  many  organs  at  once,  and  which  originate  without  any 
obvious  sign  of  inflammation.  In  instances  of  this  kind,  it  is 
impossible  not  to  see  a  constitutional  or  general  affection. — What 
has  just  been  said  of  inflammation,  applies  equally,  as  Bayle  has 
well  observed,  to  other  general  and  local  causes  to  which  some 
have  attributed  phthisis ;  such  as  syphilis,  croup,  scurvy,  erup- 
tions, &c.  These  may  hasten  the  development  of  tubercles 
already  existing ;  they  may  even  sometimes,  perhaps,  determine 
their  development  in  subjects  predisposed  to  them  :  but  in  such 
cases,  they  are  merely  occasional  causes ;  the  real  cause,  like  that 
of  all  diseases,  being  probably  beyond  our  reach.* 

*  Very  various  opinions  respecting  the  origin  and  nature  of  tubercles  have 
been  entertained  by  medical  writers ;  for  a  brief  outline  of  which  I  refer  the 
reader  to  the  very  learned  work  of  Dr.  Young  on  consumptive  diseases.  It  is 
hardly  necessary  to  refer  to  the  crude  notions  of  the  ancients  on  this  subject. 
Hippocrates  considered  them  as  owing  to  the  putrefaction  of  the  phlegm  or  bile; 
and  the  opinions  of  his  successors,  and  those  of  Galen,  for  many  centuries, 
were  equally  intellible  and  correct.  In  more  modern  times  still  greater  variety 
of  opinion  has  prevailed  respecting  tubercles.  They  have  been  considered  as 
lymphatic  glands,  rendered  visible  by  inflammation,  in  the  first  place,  and  then 
subjected  to  the  common  progress  of  this  morbid  process,  such  as  suppuration, 
ulceration,  &c.  This  was  the  opinion,  with  some  slight  difference,  of  Syl- 
vius, Wepfer,  Tralles,  and  a  great  many  of  our  more  modern  writers  ;  and  it  is 
still  that  of  M.  Broussais.  By  many  others  they  have  been  considered  as  the 
direct  product  of  inflammation  of  the  pulmonary  substance,  as  stated  in  the  text. 
Dr.  Reid,  with  many  early  writers,  considers  them  as  originating  in  an  obstruct- 
ed state  of  the  exhalent  vessels  of  the  lungs,  caused  by  the  viscidity  of  their 
contents.  Dr.  Rush  says  they  are  a  collection  of  inorganic  mucus,  &c.  The 
opinion  maintained  by  our  author,  and  which  is  lhat  of  Bayle,  and  indeed  of 
almost  every  pathologist  of  eminence  since  his  time,  is  now  almost  universally 
adopted  by  medical  men.  A  remarkable  deviation  from  this  general  assent, 
however,  (as  was  noticed  in  a  preceding  note.)  has  been  maintained  with  singu- 
lar zeal  by  one  distinguished  English  physician,  Dr.  Baron,  of  Gloucester,  who 
attempts  to  prove  that  tubercles  are  essentially  hydatids,  and  that  the  progress  of 
the  tuberculous  disease  is  precisely  the  reverse  of  that  described  by  Laennec. — 
Transl. 

The  discussion  in  the  text  respecting  the  inflammatory  or  non-inflammatory 
origin  of  tubercles  in  the  lungs,  is  now  become  idle,  since  all  good  observers 
are  of  accord  on  this  point — that  they  are  in  all  cases  the  consequence  of  a  pre- 
disposition either  congenital  or  acquired.  It  is  of  little  consequence  whether 
tubercles  are  or  are  not  the  consequence  of  inflammation,  if  it  be  shown  that 
this  consequence  can  only  ensue  under  given  circumstances.  The  only  thing 
of  importance  is  to  know  these  circumstances,  that  is,  to  ascertain  the  predispos- 
ing causes  of  phthisis,  as  it  is  on  this  knowledge  alone,  that  any  rational  treat- 
ment of  this  dreadful  disease  can  be  founded. 

I  may  here  remark,  that  with  the  exception  of  what  is  given  by  our  author  in 
the  ensuing  section,  on  the  cicatrization  of  tuberculous  cavities,  the  anatomical 
history  of  tubercles  has  been  enriched  byr  no  new  fact  since  the  labors  of  Bayle  ; 
what  M.  Andral  has  advanced  respecting  granulations  and  tuberculous  infiltra- 
tion cannot  be  considered  as  such.  M.  Rochoux  alone,  in  my  opinion,  has  any 
claim  to  be  regarded  as  having  added  any  thing  to  what  was  previously  known 
on  the  subject,  if  it  is  indeed  true,  as  he  states,  and  as  my  own  observations  lead 
me  to  believe,  that  tubercles  first  present  themselves  under  the  form  of  a  reddish 
point,  previously  to  becoming  grey  and  semi-transparent  bodies. — (M.  L.) 

The  more  I  have  studied  the  development  of  tubercles,  the  more  I  have 
felt  inclined  to  agree   with  Laennec  in  regard  to  the  effect  of  inflammation  in 


PHTHISIS    PULMONALE. 


319 


Sect.  III. — Examination  of  the  question,  whether  or  not 
Phthisis  is  curable. 

To  many  practical    physicians,  who   are  not  anatomists,    the 
possibility  of  a  cure  taking  place  after  the  formation  of  an  ulcer- 

•  mising  them.  In  the  first  edition  of  my  Clinique  Medicate,  I  affirmed  that  a 
particular  predisposition  of  the  body  was  necessary  to  their  production,  yet  I 
thought  a  certain  degree  of  hyperemia  must  necessarily  precede  them.  My 
views  on  the  point  are  modified  in  the  last  edition  of  my  Clinique,  as  well  as  in 
my  lectures  and  Pathological  Anatomy,  and  I  am  now  of  opinion  that  tubercu- 
lous matter  does  not  necessarily  depend  on  antecedent  irritation. 

It  is  certain  that  inflammation  of  every  kind  and  degree  may  exist  without 
bringing  on  tubercles.  On  the  other  hand,  tubercles  arise  without  any  possi- 
bility of  proving  either  by  the  symptoms,  or  anatomical  investigation,  that  they 
have  been  preceded  by  inflammation  or  simple  active  hyperemia.  This  is  cer- 
tainly  the  case  where  tubercles  attack  almost  all  the  organs  simultaneously. 
How  could  inflammation  or  congestion  have  existed  here  without  showing  it- 
self? And  how  happens  it,  if  after  there  has  been  inflammation,  that  the  tissue 
around  the  tubercles  is  found  perfectly  sound  in  children,  when  the  scalpel  can 
hardly  touch  a  tissue  without  meeting  a  tubercle  ?  Is  inflammation  going  on 
everywhere  ?  Certainly  not,  and  yet  whenever  tubercles  arise,  it  is  asserted 
there  must  have  been  if  not  inflammation,  at  least  irritation,  and  consequently 
active  hyperemia.  I  utterly  deny  that  in  a  great  number  of  cases  there  is  any 
antecedent  irritation  either  of  the  red  vessels  or  the  white.  How  often  do  we 
find  tubercles  in  the  brain  without  any  symptom  of  irritation  having  been  man- 
ifested during  life.  These  symptoms  for  the  most  part,  appear  subsequently, 
and  when  the  tubercle  has  increased  so  far  as  to  press  upon  the  nervous  pulp 
around  it.  In  these  cases,  too,  the  symptoms  happen  only  with  intermissions. 
During  the  intervals,  order  is  restored,  and  no  symptom  of  any  lesion  is  percep- 
tible. No  doubt,  in  many  cases  the  tubercles  seem  to  originate  at  the  time  the 
patient  takes  his  first  cold.  Previous  to  this,  no  signs  of  pectoral  affection 
appeared.  It  is  by  mere  hypothesis  in  this  case  that  we  suppose  the  pre-exist- 
ence  of  tubercles,  and  it  is  probable  that  bronchitis  is  the  occasional  cause  of 
their  development.  But  is  this  always  the  case  ?  No.  Examine  carefully  con- 
sumptive patients  ;  in  one  half  of  them  at  least,  we  shall  find  that  before  they 
had  any  cough,  they  were  troubled  with  a  slight  dyspnoea,  sometimes  from  early 
infancy,  which  hindered  them  from  running,  climbing,  &c.  They  will  tell  us 
they  were  at  the  same  time  meagre,  pale  and  delicate.  Many  years  pass  in  this 
manner;  then  they  take  cold,  and  cough  and  other  symptoms  of  consumption 
appear.  What  is  the  cause  of  this  dyspnoea,  if  it  be  not  the  presence  of  tuber- 
cfes  in  the  lungs,  mechanically  obstructing  their  movements?  How  can  it  be 
made  to  appear  that  irritation  has  caused  these  tubercles  ?  This  would  be  still 
more  difficult  where  tubercles  exist  at  the  same  time  in  the  liver,  spleen,  kid- 
neys, bones  and  lymphatic  glands,  for  the  development  of  tubercle  is  completely 
latent  in  all  these  parts.  There  is  thus  a  period  in  the  existence  of  tubercles 
when  they  afford  no  symptom  whatever,  except  in  some  instances  by  a  mechani- 
cal trouble  in  the  organ  they  attack.  Afterward  they  bring  around  them  an 
irritation  which  draws  them  out  of  their  latent  state.  Irritation,  therefore,  in 
such  a  case,  is  not  the  cause,  but  the  effect  of  the  development  of  tubercles. 

Tubercles  may,  nevertheless,  be  developed  by  an  inflammation  which  dis- 
turbs the  process  of  nutrition.  By  generalizing  too  far  upon  these  cases,  it 
has  been  pretended  that  all  tubercles  arise  from  inflammation,  or  something 
equivalent.  Inflammation  alone,  whatever  may  be  its  duration,  intensity  or  seat, 
ne\  (  r  can  create  tuberculous  matter.  Its  formation  is  determined  by  the  innate 
or  acquired  disposition  of  the  organization,  before  inflammation  or  hyperemia 
attacks  it.  Here  inflammation  assists  the  formation  of  the  tubercles  by  quicken- 
ing the  tuberculous  disposition  already  existing.  In  this  manner  we  see  children 
become  rapidly  consumptive  after  hooping  cough  or  measles  ;  we  see  them  too, 


320  PHTHISIS    PULMONALIS. 

ous  excavation  in  the  lungs  may  seem  quite  admissible.  This 
opinion,  however,  will,  in  all  likelihood,  appear  quite  absurd  to 
those  who  have  paid  much  attention  to  morbid  dissection.  Pre- 
viously to  the  knowledge  of  the  true  character  and  mode  of  de- 
velopment of  tubercles,  and  while  consumption  was  considered 
simply  as  a  consequence  of  the  chronic  inflammation  and  slow 
suppuration  of  the  pulmonary  tissue,  medical  men  did  not  ques- 
tion (any  more  than  the  vulgar  do  now)  the  possibility  of  curing 
this  disease  by  a  suitable  mode  of  treatment,  especially  if  taken 
in  time,  and  during  the  first  stage  of  it.  M.  Broussais  still 
flatters  himself  with  the  same  hope.  (Exam,  des  Doct.  Med.) 
It  is  now,  however,  the  general  opinion  of  all  those  who  are  ac- 
quainted with  the  actual  state  of  out  knowledge  respecting  the 
pathology  of  diseases,  that  the  tubercular  affection,  like  cancer, 
is  absolutely  incurable,  inasmuch  as  nature's  efforts  towards 
effecting  a  cure  are  injurious,  and  those  of  art  are  useless.     Bayle, 

attacked  by  tuberculous  degeneration  of  the  glands  of  the  mesentery  after  long 
and  frequent  diarrhcea.  Without  this  predisposition,  irritation  would  have  no 
effect  in  the  development  of  tubercles. 

The  power  of  irritation  in  producing  tubercles  is  very  accurately  represented 
in  the  following  statement  of  M.  Benoiston  de  Chateauneuf.  He  has  made  a 
comparison  of  the  number  of  deaths  by  consumption  among  1.  Soldiers.  "2.  Mu- 
sicians in  the  army  who  play  on  wind  instruments.  3.  Men  between  twenty 
and  thirty  years  of  age,  other  than  those  already  mentioned.  The  result  is, 
that  among  the  soldiers  the  mortality  is  1  in  14;  among  musicians  1  in  7  ;  and 
in  the  last-mentioned  class  1  in  3|. 

It  is  remarkable  that  the  mortality  is  so  much  less  in  the  first  two  classes  than 
in  the  third.  This  is  explained  by  the  fact  that  soldiers  are  picked  men,  and  in 
time  of  peace  at  least,  are  subjected  to  a  healthy  regimen  and  discipline.  But 
among  these  soldiers,  are  some  who  by  their  occupation  of  blowing  wind  in- 
struments, expose  their  lungs  to  a  constant  fatigue  ;  consumption  carries  ofF 
more  of  these  than  of  the  other  soldiers.  This  habitual  irritation  of  the  lungs 
has  an  evident  influence  in  the  disease,  but  is  it  the  sole  cause  ?  Certainly  not  ; 
— it  only  helps  on  the  predisposition.  If  it  were  otherwise,  the  musicians  of 
the  army  would  die  consumptive  in  as  great  number  as  the  other  men  between 
twenty  and  thirty  ;  and  this,  as  we  have  seen,  is  not  the  fact.  These  views 
lead  me  to  the  following  conclusions. 

1.  Tubercles,  like  many  other  accidental  productions,  may  originate  and  be 
developed  without  any  increase  in  the  normal  excitability  of  the  part  in  which 
they  arise.  There  is,  therefore,  no  necessity  of  a  preceding  inflammation,  or 
even  simple,  active  hyperaemia. 

2.  They  must  be  regarded  as  the  result  of  a  special  modification  of  the  func- 
tions of  nutrition  and  secretion.  There  is  no  more  necessity  for  irritation  to 
produce  a  tubercle,  than  to  secrete  bile. 

3.  The  persons  most  disposed  to  this  modification,  are  those  whose  organic 
development  seems  to  be  imperfect; — those  in  whom  the  lymphatic  tempera- 
ment predominates.  This  is  the  most  general  predisposition  to  tuberculization, 
yet  tubercles  may  arise  without  it. 

4.  Irritation  in  every  form  and  degree,  has  often  a  great  influence  in  the  pro- 
duction of  tubercles  ;  but  is  never  any  thing  more  than  the  occasional  cause  ; 
it  merely  acts  upon  the  predisposition,  which  otherwise  might  long  remain 
latent. 

5.  Irritation  does  not  always  precede  tubercles,  but  always  follows  them.  In 
every  case  where  an  organ  is  attacked  by  tubercles,  a  reaction. is  produced 
around  them,  which  brings  on  an  inflammatory 'state  and  tends  to  the  expulsion 
of  the  tubercles. — Andral. 


PHTHISIS     I'ULMONaLIS. 


321 


in  particular,  advocates  the  incurability  of  this  disease ;  he, 
however,  admits  the  possibility  of  its  being  almost  indefinitely 
prolonged.  The  recent  researches  made  in  England  and  Ger- 
many have  led  the  best  informed  physicians  of  those  countries  to 
the  same  result.  The  observations  contained  in  the  treatise  of 
M.  Baylc,  as  well  as  the  remarks  made  in  the  present  chapter,  on 
the  development  of  tubercles,  sufficiently  prove  the  idea  of  the 
cure  of  consumption  in  its  early  stage  to  be  perfectly  illusive. 
Crude  tubercles  tend  essentially  to  increase  in  size  and  to  become 
soft.  Nature  and  art  may  retard  or  even  arrest  their  progress, 
but  neither  can  reverse  it.  But  while  I  admit  the  incurability  of 
consumption  in  the  early  stages,  I  am  convinced,  from  a  great 
number  of  facts,  that,  in  some  cases,  the  disease  is  curable  in  the 
latter  stages,  that  is,  after  the  softening  of  the  tubercles  and  the 
formation  of  an  ulcerous  excavation. 

Occasionally,  while  examining  the  lungs  of  subjects  that  had 
suffered  from  chronic  catarrh,  I  have  observed  irregular  cavities 
lined  by  a  semi-cartilaginous  membrane  in  all  respects  similar  to 
that  described  above  ;  and  these  cavities  accorded  perfectly  with 
the  tuberculous  ulcerations,  except  that  they  were  empty.  In 
carefully  investigating  the  history  of  such  subjects,  I  found 
that  they  all  referred  the  origin  of  their  catarrh  to  a  severe  pre- 
vious disease,  which  bore  the  character  of  consumption,  so  strongly 
as  to  make  their  case,  at  the  time,  be  considered  desperate.  On 
the  other  hand,  in  subjects  dead  of  consumption,  whose  disease 
had  lasted  very  long,  several  years  for  instance,  we  very  com- 
monly find  similar  excavations  entirely  lined  by  semi-cartilagi- 
nous membrane,  and  free,  or  almost  free,  from  tuberculous 
matter.  In  the  same  lung  we  shall  also  find  excavations  having 
the  cartilaginous  membrane  much  softer  and  less  complete,  and 
still  containing  a  considerable  quantity  of  tuberculous  matter ; 
while  other  excavations  are  observed  almost  filled  with  the  puri- 
form  tuberculous  fluid,  and  with  scarcely  any  of  the  cartilaginous 
lining.  In  conjunction  with  all  these,  we  almost  always  find 
tubercles  in  various  degrees  of  maturation,  and  even  in  their 
miliary  and  semi-transparent  stage.  This  re-union  of  tubercles 
in  all  their  various  degrees  of  development,  considered  in  con- 
junction with  the  slow  progress  of  the  disease,  decidedly  proves 
in  my  opinion,  that  the  tubercles  have  been  developed  at  different 
periods ;  and  that  the  oldest — those  namely,  which  have  given 
rise  to  the  empty  ulcerous  cavities  lined  by  the  cartilaginous 
membrane — have  originated,  in  many  cases,  several  years  before 
the  others.  The  formation  of  the  semi-cartilaginous  membrane 
on  the  surface  of  tuberculous  excavations,  must  be  considered,  in 
my  opinion,  as  a  curative  effort  of  nature.  When  completely 
formed,  it  constitutes  a  sort  of  internal  cicatrix  analogous  to  a 
41 


322  PHTHISIS     PULM0NAL1S. 

fistula,  and  is,  in  many  cases,  not  more  injurious  to  health  than 
this  species  of  morbid  affection.  All  the  persons  whose  cases  I 
noticed  above,  died  of  diseases  not  referable  to  the  pulmonary 
organs.  They  had  all  lived  a  greater  or  less  number  of  years  in 
a  very  supportable  state  of  health,  being  merely  subject  to 
chronic  catarrh.  Some  indeed  had  more  or  less  of  dyspnoea,  but 
without  any  fever  or  emaciation. 

I  have  within  these  few  years  had  under  my  care  several  pa- 
tients affected  with  chronic  catarrh,  and  who  afforded  distinctly 
the  sign  of  pectoriloquy,  although  they  had  in  no  other  respect 
any  symptom  of  consumption.  I  have  met  with  several  other 
cases,  wherein  this  phenomenon  was  observable  along  with  a 
slight  habitual  cough,  very  little  expectoration,  and  scarcely  any 
marked  alteration  in  the  general  health.  In  a  lady,  formerly  a 
patient  of  M.  Bayle,  fourteen  years  since,  and  whose  case  was 
decidedly  consumption,  (as  appears  from  M.  Bayle's  notes  in  her 
possession,)  the  sign  of  pectoriloquy  is  most  distinct.  This  lady 
recovered  beyond  all  expectation ;  she  is  now  stout,  and  the  only 
symptom  she  has  at  all  referable  to  the  lungs,  is  a  slight  cough. 
I  have  no  doubt  that  the  cartilaginous  excavations  above  de- 
scribed exist  in  this  person's  lungs. 

Indeed,  I  feel  assured  that  when  the  use  of  the  stethoscope  be- 
comes more  general,  it  will  be  found  that  in  those  cases  in  which 
a  well-marked  phthisis  attended  by  pectoriloquy,  is  converted 
into  a  chronic  catarrh,  the  pectoriloquy  will  frequently  continue 
through  life,  and  anfractuous  cavities,  lined  by  a  semi-cartilagi- 
nous membrane,  will  often  be  found  in  the  lungs  after  death. 
Many  cases  of  this  kind  have  been  communicated  to  me  since 
the  publication  of  the  first  edition  of  this  work ;  several  others 
have  been  recorded  in  the  medical  journals  ;  and  1  have  myself 
collected  a  considerable  number.  To  render  the  statements  just 
made,  more  clear  and  intelligible,  I  shall  now  detail  five  cases, 
which  exhibit  instances  of  the  facts  I  have  related. 

Case  XVII.  Ulcers  of  the  lungs  cured  by  transformation  in- 
to semi-cartilaginous  fistula. — A  woman,  aged  sixty-eight,  had 
been  for  several  years  affected  with  much  cough  and  expectora- 
tion ;  accompanied  by  habitual  shortness  of  breath,  greatly  aggra- 
vated by  the  least  exercise.  In  other  respects  she  was  pretty 
well,  and  was  able  to  discharge  the  laborious  duties  of  a  servant. 
She  was  sufficiently  stout  and  had  a  good  appetite  ;  but  her  lips 
and  cheeks  were  of  a  bluish  red  color.  On  the  last  day  of 
December,  1817,  she  was  seized  with  fever,  very  severe  dyspnoea, 
and  cough  attended  by  very  viscid  frothy  sputa,  of  a  pale  green 
color  and  semi-opaque.  She  was  bled,  and  thereby  obtained 
some  relief.  Four  days  after  this  attack  she  was  removed  to  the 
hospital,  and  presented  the  following  symptoms  on  being  exam- 


PHTHISIS     PULMONALIS. 


323 


ined  by  the  stethoscope : — Respiration  was  barely  perceptible  to 
the  height  of  about  the  fourth  rib,  and  was  accompanied  by  a 
well-marked  crepitous   rhonchus  in  the  inferior  and  left  part  of 
the  chest.    Percussion  elicited  a  dull  sound  over  the  same  extent, 
especially   on   the  back.     The  pulsation  of  the  heart  gave  no 
shock,  but  was   perceptible  over  the  whole  anterior  and  lateral 
part  of  the  chest,  and  slightly  on  the  left  side  of  the  back.     The 
contraction  of  the  auricles  and  ventricles  produced  a  considera- 
ble sound,  and  nearly  equally  so.     The  external  jugulars   were 
swollen.     The  dyspnoea  and  expectoration  were  as  stated  above. 
On  these  data  the  following  diagnostic  was  given ;  Pneumonia 
of  the  inferior  part  of  the  left  lung :  slight  dilatation  of  the 
ventricles.     Fresh  bleedings  gave  temporary  relief;    but  on  the 
eighth  day  the  fever  increased  and  was  attended  by  stupor  and 
delirium.     At  this  time   respiration  was  much  stronger  (caver- 
nous) on  the  upper  part  of  the  left  side  than  anywhere  else,  and 
naturally  led  us  to  suspect  the   existence  of  pectoriloquy   there ; 
but  the  patient  was  too  weak  to  have  this  tried,  and  died  the  fol- 
lowing day. 

Dissection  twenty-four  hours  after  death. — The  lungs  ad- 
hered to  the  costal  pleura,  nearly  through  their  whole  extent,  by 
means  of  well-organized  cellular  substance,  evidently  of  ancient 
date.  The  right  lung  was  crepitous  and  very  sound,  exclusive 
of  the  upper  lobe,  which  contained  an  excavation  of  the  size  of 
a  large  filbert.  This  was  lined  by  a  thin,  smooth,  equable  mem- 
brane, pearl-grey,  and  of  a  semi-cartilaginous  nature.  Several 
bronchial  tubes  opened  into  this,  extremely  dilated,  so  as,  at  first 
sight,  to  look  like  appendices  of  the  cavity.  The  mucous  mem- 
brane of  some  of  these  tubes  was  very  pale,  and  that  of  others 
red,  but  not  swollen.  The  top  of  the  left  lung  contained  a  simi- 
lar cavity,  only  larger,  being  capable  of  containing  a  walnut, 
and  more  irregularly  shaped.  It  was  lined  by  a  membrane  of 
the  same  kind,  which  was  continuous  with  the  mucous  coat  of 
a  great  number  of  bronchial  tubes,  of  the  size  of  a  crow-quill, 
which  opened  into  it.  It  contained  merely  a  small  portion  of 
nearly  colorless  serosity.  The  substance  of  the  lungs  around 
these  cavities  was  sound  and  crepitous ;  except  in  the  places 
where  some  of  the  projecting  angles  came  nearly  in  contact,  in 
which  cases  the  intervening  substance  appeared  like  a  compound 
of  fibro-cartilage  and  black  pulmonary  matter.  There  were  no 
tubercles  whatever  in  the  lungs  ;  but  the  whole  of  the  inferior 
lobes,  and  the  lower  portion  of  the  superior,  had  a  consistence 
equal  to  that  of  liver,  which,  when  cut,  exhibited  a  granulated 
surface,  and  poured  out  a  purulent  fluid  intermixed  with  blood. 
The  right  cavity  of  the  chest  was  larger  than  the  left.  The 
heart  was  somewhat  larger  than  natural,  and  was  filled  with  co- 


324  PHTHISIS    PULMONALIS. 

agula.     Tho  right  ventricle,  in  particular,  was  evidently  enlarged, 
and  both  these  were  thin,  especially  the  right. 

Case  XVIII.  Ulcer  of  the  lungs  converted  into  a  semi-carti- 
laginous fistula.  A  man,  aged  thirty-two,  affected  at  intervals 
during  the  preceding  six  months,  with  mania,  was  brought  to 
Necker  Hospital  26th  December,  1817,  in  a  state  of  stupor,  and 
died  a  few  days  afterwards.  Sufficient  cause  of  death  was  found 
in  the  brain.  I  shall  only  here  notice  the  condition  of  the  lungs. 
The  left  lung  was  one-fourth  less  than  the  right,  and  adhered  by 
numerous  cellular  attachments  to  the  pleura.  It  was,  through- 
out, sound  and  crepitous,  but  contained  about  seven  or  eight 
tubercles  of  the  size  of  hemp-seed,  having  a  yellow  and  opaque 
speck  in  their  centre.  The  right  lung  was  in  its  summit  attached 
to  the  pleura,  by  old  adhesions,  and  contained,  in  this  place,  an 
excavation  capable  of  holding  an  egg.  This  cavity,  which  was 
filled  by  a  clot  of  blood,  was  lined  by  a  semi-cartilaginous  mem- 
brane, a  quarter  of  a  line  thick,  of  a  pearl-grey  color,  and  very 
smooth  and  polished,  yet  having  little  tuberosities  on  its  surface. 
Several  bronchial  tubes  of  different  diameters  opened  into  it. 
The  rest  of  the  lung  was  perfectly  crepitous  throughout,  even 
around  the  excavation,  but  contained  an  immense  quantity  of 
tuberculous  granulations,  of  the  size  of  millet  seed  at  most,  be- 
sides three  or  four  other  tubercles  of  a  larger  size,  and  already 
yellow,  opaque,  and  somewhat  friable  towards  their  centre. 

Case  XIX.  Ulcer  of  the  lungs  converted  into  a  semi-carti- 
laginous fistula,  fyc. — A  woman,  aged  forty,  had  been  long  sub- 
ject to  much  cough  and  dyspnoea,  varied  by  temporary  aggra- 
vations, especially  during  certain  states  of  the  weather.  These 
symptoms,  which  she  called  asthma,  had  not  incapacitated  her 
for  labor,  until  the  last  fifteen  days,  at  the  end  of  which  time 
she  came  into  the  hospital.  At  this  time  she  could  not  at  all  lie 
down, — the  respiration  was  very  short  and  difficult, — the  face 
pallid  and  swollen,  and  the  lips  blue,  and  there  was  anasarca  of 
the  lower  limbs.  The  chest  yielded,  on  percussion,  a  pretty  good 
sound  throughout,  though,  perhaps,  somewhat  less  than  natural. 
Immediately  below  the  clavicle  on  each  side,  the  cylinder  dis- 
covered a  well-marked  rhonchus.  The  thoracic  parietes  were 
much  and  forcibly  elevated  at  each  inspiration.  The  cough  was 
very  frequent,  and  followed  by  expectoration  of  opaque  yellow 
sputa.  Pectoriloquy  was  not  discoverable.  The  pulse  was  fre- 
quent, small,  and  regular ;  the  external  jugulars  were  swelled  and 
distinctly  pulsative;  the  pulsations  of  the  heart,  examined  by 
the  stethoscope,  were  deep  and  regular,  but  affording  little  sound 
and  no  impulse  to  the  ear.  From  this  examination  I  thought 
myself  justified  in  considering  the  heart  as  sound,  notwithstand- 
ing the  contrary  indication  afforded  by  the   general  symptoms ; 


PHTHISIS    PULMONALIS. 


325 


and  accordingly  gave  my  diagnosis — Phthisis  without  disease 
of  the  heart.  (Four  leeches  to  the  epigastrium ;  pectoral  mix- 
ture.) A  few  days  after,  the  contraction  of'  the  ventricles  gave 
some  impulse,  a  symptom  which,  taken  along  with  the  pulsation 
of  the  jugulars,  gave  reason  to  suspect  slight  hypertrophy  of  the 
right  ventricle.  The  symptoms,  especially  the  anasarca,  got  gra- 
dually worse;  and  she  died  on  the  19th  of  February.  The  day 
before  her  death  evident  pectoriloquy  was  discovered  about  the 
anterior  third  of  the  fourth  intercostal  space,  on  the  right  side,  a 
point  which  had  not  been  examined  before. 

Dissection. — The  heart  was  of  the  natural  size.  The  right 
ventricle  was  perhaps  a  little  thicker  than  natural ;  and  there 
was  an  ecchymosed  spot,  the  size  of  the  nail,  on  the  inner  sur- 
face of  the  pericardium.  There  was  about  a  pint  of  serum  in 
the  left  side  of  the  chest,  and  the  lung  was  attached  to  the  costal 
pleura,  at  its  top,  by  short  cellular  adhesions.  In  this  point 
there  were  several  radiated  linear  impressions  depressed  in  the 
point  of  their  union.  These  impressions  corresponded  to  three 
or  four  laminae  of  condensed  cellular  tissue  traversing  the  sub- 
stance of  the  lung.  In  the  same  place  there  was  a  dozen  of  tu- 
bercles in  different  stages,  and  one  small  excavation  of  the  size 
of  a  filbert,  lined  by  a  soft  membrane,  and  filled  by  softened 
tuberculous  matter.  The  rest  of  this  lung  was  crepitous  and 
gorged  with  blood.  The  right  lung  adhered  firmly,  throughout 
its  whole  extent,  to  the  costal  pleura.  Immediately  opposite  the 
fourth  intercostal  space,  and  at  the  depth  of  half  an  inch,  there 
was  a  cavity  the  size  of  a  walnut.  It  was  lined  by  a  semi-carti- 
laginous membrane,  of  the  kind  so  often  already  described,  and 
contained  a  small  portion  of  a  yellowish  pus.  A  bronchial  tube 
opened  into  this  on  the  inferior  side,  of  the  size  of  a  crow-quill, 
but  partially  obstructed  by  a  small  chalky  concretion  which  lay 
loose  in  it.  There  were  seven  or  eight  similar  concretions  in  other 
parts  of  the  lung,  two  of  which,  situated  immediately  under  the 
pleura,  were  of  the  size  of  prune-stones.  The  lungs  were  in  other 
respects  sound. 

Case  XX.  Phthisis  Pulmonalis — cured  by  the  conversion  of 
an  ulcerous  excavation  into  a  fistula. — This  patient  was  a  lady, 
aged  forty-eight,  of  a  good  constitution,  and  had  been  healthy, 
with  the  exception  of  a  local  disease,  until  her  thirtieth  year, 
when  she  became  subject  to  very  severe  pulmonary  catarrhs, 
several  of  which  confined  her  to  bed  for  two  or  three  months,  and 
produced  considerable  emaciation.  Subsequently  to  one  of  these 
attacks  she  had  a  diarrhoea,  which  was  at  length  checked  with 
great  difficulty,  but  her  bowels  continued  lax  for  several  years. 
After  being  long  without  an  attack  of  catarrh,  and  in  very  good 
health,  she  was,  in  the  beginning  of  1817,  attacked  with  a  dis- 


326  PHTHISIS     PULMONALIS. 

tressing  cough,  attended  by  a  slight  watery  viscid  and  colorless 
expectoration.  I  saw  her  in  July,  at  which  time  she  was  con- 
siderably emaciated,  and,  though  still  able  to  attend  to  her  occu- 
pation, weak  and  languid.  The  pulse  and  skin  were  not  uni- 
formly febrile.  Respiration  was  very  perceptible  over  the  whole 
chest,  but  less  distinctly  at  the  top  of  the  right  lung.  From 
this,  and  the  nature  of  the  expectoration,  I  considered  her  as 
having  tubercles  in  an  early  stage,  and  applied  leeches,  &c.  The 
symptoms  continued  nearly  the  same  throughout  the  summer 
and  part  of  the  winter.  In  the  end  of  February,  1818,  the 
cough  became  suddenly  loose,  and  the  patient  began  to  have 
thick  yellow  puriform  expectoration.  This  state  of  the  sputa 
lasted  a  month,  when  the  cough  in  a  great  measure  left  her  and 
became  nearly  dry.  I  did  not  see  the  patient  during  this  attack, 
which  she  looked  upon  as  a  cold ;  but  I  visited  her  in  the  be- 
ginning of  April,  and  upon  examining  her  chest  I  found  most 
distinct  pectoriloquy  at  the  anterior  and  upper  part  of  the  right 
side.  I  was  convinced  by  this  that  the  supposed  catarrh  had 
been  the  discharge  of  the  softened  tuberculous  matter.  The 
sound  of  respiration  was  good  over  the  whole  chest ;  and  even  in 
the  vicinity  of  the  pectoriloquous  spot ;  the  pulse  was  not  fre- 
quent and  the  heat  moderate.  On  this  account  I  entertained 
hopes  of  her  recovery,  and  prescribed  ass's  milk.  The  cough 
and  expectoration  progressively  lessened,  the  flesh  and  strength 
returned ;  and,  in  the  beginning  of  July,  my  patient  had  regained 
every  appearance  of  the  most  perfect  health,  although  the  pecto- 
riloquy still  continued  most  distinct,  beneath  the  anterior  part  of 
the  second  rib  on  the  right  side,  in  a  space  of  about  an  inch 
square.  During  the  succeeding  winter  this  lady  had  an  attack 
of  catarrh,  but  it  lasted  only  fifteen  days  and  was  not  severe.  In 
other  respects  she  bore  ihe  winter  well,  and  she  continues  in 
good  health,  though  still  pectoriloquous  in  the  same  degree.  Her 
pulse  is  rather  slow,  and  she  has  little  cough  and  less  expectora- 
tion. 

From  considering  the  foregoing  observations,  the  shape  of  the 
pulmonary  fistula?,  the  smooth  and  polished  surface  of  their 
lining  membrane,  and  the  analogy  of  fistulse  in  other  parts  of  the 
body,  we  might  naturally  be  led  to  suppose  that  the  formation  of 
the  semi-cartilaginous  membrane  is  the  last  effort  of  nature  to- 
wards a  cure,  after  the  formation  of  an  ulcerous  excavation  in  the 
substance  of  the  lungs,  and  that  it  is  impossible  for  the  walls  of  a 
cavity  lined  by  such  a  membrane  to  unite  and  cicatrize.  The 
following  case,  however,  leads  me  to  the  contrary  conclusion. 

Case  XXI.  Semi-cartilaginous  fistula  of  the  lungs  par- 
tially cicatrized,  ty-c. — A  patient,  admitted  into  the  hospital  for  a 
diarrhoea,  and  who  was  observed  during  the  time  he  remained 


PHTHISIS     PULM0NALI9. 


327 


there  to  have  also  cough  and  expectoration,  died  suddenly  of 
apoplexy,  the  cause  of  which  was  found  in  the  brain.  Upon  ex- 
amining the  chest,  the  right  lung,  at  its  summit,  was  found  to 
adhere,  by  means  of  long  cellular  attachments,  to  the  pleura. 
In  the  lateral  and  posterior  part  of  the  upper  lobe,  there  was 
observed  on  the  surface  a  deep  depression,  which  seemed,  at  first 
sight,  owing  to  the  falling  in  of  the  walls  of  an  ulcerous  excava- 
tion, but  which  felt  to  the  touch  very  solid  and  resisting.  Upon 
dividing  the  lung  in  this  point,  it  was  found  that  there  extended 
inwards  from  the  centre  of  this  depression,  a  white  opaque  lamina, 
about  half  a  line  in  thickness  and  of  the  consistence  of  cartilage, 
only  hardly  so  firm.  When  it  had  reached  to  within  half  an 
inch  of  the  opposite  surface  of  the  lung,  this  lamina  divided  into 
two  parts  and  then  re-united,  so  as  to  leave  a  small  cavity  or 
cyst  capable  of  containing  an  almond  or  prune-stone.  This 
cavity  was  half-filled  by  a  flake  of  tuberculous  matter  of  a  yel- 
lowish white  color,  opaque,  friable,  much  drier  than  tubercu- 
lous matter  of  this  consistence  usually  is,  but  still  easily  recog- 
nized as  such,  as  well  by  its  peculiar  characters,  as  from  some 
specks  of  black  pulmonary  matter  with  which  it  was  intermixed. 
The  walls  of  this  cavity,  being  only  one-half  as  thick  as  the  car- 
tilaginous lamina  with  which  they  are  connected,  and  of  which 
they  appeared  to  be  a  separation,  were  slightly  semi-transparent, 
and  exhibited  the  reddish  tint  of  the  pulmonary  substance  sur- 
rounding them.  About  two  lines  above  this  membrane,  at  the 
very  top  of  the  lung,  there  was  found  a  portion  of  the  pulmo- 
nary substance,  about  an  inch  square,  quite  indurated.  This  in- 
duration was  occasioned  by  a  great  number  of  small  tubercles, 
of  a  whitish-yellow  color,  opaque  in  the  centre,  grey  and  semi- 
transparent  towards  the  circumference,  quite  distinct  from  each 
other,  and  varying  in  size  from  that  of  a  millet  to  that  of  a 
hemp-seed.  Some  of  them  were  quite  white  and  opaque,  and 
were  beginning  to  soften  in  their  centre.  The  intervening  pul- 
monary substance  was  infiltrated  by  a  semi-transparent  sero-san- 
guineous  and  jelly-like  matter,  much  more  solid  than  jelly,  though 
still  very  humid.  (Jelly-like  tuberculous  infiltration.)  Many 
other  similar  tubercles  were  contained  in  different  parts  of  this 
lung,  which  was,  nevertheless,  crepitous  throughout,  with  the 
exception  of  the  indurated  spot  above-mentioned,  and  a  portion 
of  the  inferior  and  back  parts,  which  were  considerably  engorged. 
The  left  lung  was  charged  with  tubercles  precisely  in  the  same 
manner  as  the  right,  and  contained  in  the  upper  part  of  the  supe- 
rior lobe,  a  cavity  somewhat  irregularly  shaped,  capable  of  hold- 
ing an  almond  in  its  shell.  This  was  entirely  empty,  and  cover- 
ed by  a  membrane  about  a  quarter  of  a  line  in  thickness,  which  was 
smooth,  even,  semi-transparent,  and  of  the  consistence  of  carti- 


328  PHTHISIS    PULN0NAL1S. 

lage,  but  more  friable.  Five  or  six  bronchial  tubes  opened  into 
this  cavity,  their  inner  membrane  appearing  continuous  with  it. 
The  substance  of  the  lungs  around  was  quite  sound  and  crepitat- 
ing.* 

The  foregoing  condition  of  parts  appears  to  me  evidently  pro- 
duced by  the  imperfect  union  of  the  membrane  lining  two  sides 
of  an  ulcerous  excavation,  and  which  has  been  rendered  imperfect 
by  the  portion  of  tuberculous  matter  still  remaining  in  it  at  the 
period  of  union.  This  must  be  regarded  as  a  very  rare  oc- 
currence. It  is  the  only  one  of  the  kind  I  have  met  with.  It 
is,  however,  not  at  all  uncommon  to  find  in  different  parts  of  the 
lungs,  especially  in  the  upper  part  of  the  superior  lobes,  (in  which 
situation  tubercles  are  well  known  to  be  of  most  frequent  occur- 
rence,) bands  composed  of  a  condensed  cellular  substance,  inter- 
mixed sometimes  with  fibrous,  or  fibro-cartilaginous  portions, 
which  by  their  whiteness  form  a  striking  contrast  with  the  natural 
tissue  of  the  lungs.  These  bands  have  every  resemblance  to 
cicatrices  in  the  pulmonary  substance.  Sometimes,  in  place  of 
these  bands,  we  observe  masses  of  various  size,  of  condensed 
cellular  or  fibro-cartilaginous  tissue.  Commonly,  the  substance 
of  the  lungs  in  the  vicinity  of  these  accidental  productions,  is 
much  more  impregnated  with  the  black  pulmonary  matter  than 
elsewhere  ;  so  much  so,  that  it  would  seem  as  if  the  formation  of 
such  foreign  bodies  were  necessarily  accompanied  by  an  extraor- 
dinary secretion  of  this  peculiar  matter,  which  ought  not  to  be 
considered  as  a  morbid  production.  The  parts  most  deeply  im- 
pregnated with  this  matter,  are  commonly  more  flabby  and  less 
crepitous  than  natural,  and  have  intermixed  with  them  fibro- 
cartilaginous bands.  It  is  not  uncommon  to  find  in  such  lungs 
concretions  of  a  bony  or  earthy  nature  :  or  a  chalky  substance, 
of  the  consistence  of  paste. 

I  had  often  observed  the  above  state  of  things  without  know- 
ing to  what  to  attribute  it,  and  without  attaching  much  impor- 
tance to  the  appearance  ;  but  after  I  was  convinced  of  the  possi- 
bility to  cure  in  the  case  of  ulcerations  of  the  lungs,  I  began  to 
fancy  that  nature  might  have  more  ways  than  one  of  accomplish- 
ing this  end,  and  that,  in  certain  cases,  the  excavations,  after  the 
discharge  of  their  contents,  by  expectoration  or  absorption,  might 
cicatrize  in  the  same  manner  as  solutions  of  continuity  in  other 
organs,  without  the  previous  formation  of  the  semi-cartilaginous 
membrane.  In  consequence  of  this  idea,  I  examined  these  pro- 
ductions more  closely,  and  came  to  the  conclusion,  that,  in  every 
case,  they  might  be  considered  as  cicatrices,  and  that,  in  many 

*  This  excavation  would  have  infallibly  given  the  most  perfect  pectoriloquy, 
if  it  had  been  sought  for.— Author. 


PHTHISIS    PULMONALIS. 


329 


cases,  they  could  hardly  be  conceived  to  be  any  thing  else.     In 
all  such  examples  of  supposed  cicatrization,  I  found  on  the  ex- 
terior of  the  lung,  at  the  point  nearest  to  such  cicatrice,  a  depres- 
sion of  greater  or  less  extent,  with  a  hard  and  irregular  surface, 
furrowed  by  linear  marks,  which  sometimes  exhibited  an  irregular 
net  work,  or  embroidery,  and  sometimes  resembled  the  mouth  of 
a  purse,  by  their  common  union  in  one  central    point.     In  the 
same  place  there  are  usually  found  adhesions  between  the  pleura 
of  the  ribs  and  lungs.     These  depressions  are  found  most  fre- 
quently on  the  posterior   or   exterior   side  of  the  upper  lobes. 
When  they  are  very  deep,  it  sometimes  happens  that  the  anterior 
part  of  the  lobe,  drawn  upwards  and  backwards  by  the  apparent 
loss  of  substance  and  consequent  falling-in  of  the  part,  overlaps 
the  depressed  portion  like  the  crest  of  a  helmet.     The  posterior 
portion  of  the  lung  has  sometimes  the  same  appearance,  but  in  a 
manner  much  less  strongly  marked.     Whatever  resemblance  these 
depressions  may  have   to  cicatrices,  I  do  not  consider  them  as 
really  such,   but  rather  as  analogous  to  those  depressions  met 
with  in  scirrhus  mammae,  which  are,  in  like  manner,  occasioned 
by  the  diseased  action  going  on  in  the  substance  within.     In  the 
one  case,  the  surface  of  the  lungs,  in  the  other  the  skin,  is  re- 
tracted by  the  shrinking  of  the  subjacent  parts.     In  carefully  ex- 
amining such  lungs  as  showed  similar  depressions  on  their  sur- 
face, I  have  invariably  found,  at  the   depth  of  half  a  line,  a  line, 
or  two  lines  at  farthest,  a  cellular,  fibrous,  or  fibro-cartilaginous 
mass,  similar  to  those  described  above.     The  pulmonary  tissue 
comprehended   within    the   depressed    space,    is   almost  always 
flabby,  and  not  crepitous,  even  in  cases  where  there  is  no  sign  of 
congestion  or  of  impregnation  with  the  black  pulmonary  matter. 
Every  where  else,  however,  in  the  vicinity  of  these  productions, 
the  lung   is   frequently  quite   sound.     In   tracing  the  bronchial 
tubes  near  these  masses,  I  have  observed  that  such  as  held  a 
direction  towards  them,  were  commonly  dilated.     In  some  cases 
I  have  been  able  to  trace  them,  as  also  bloodvessels,  in  the  fibro- 
cartilaginous mass,  with  which,  although  obliterated,  they  formed 
but  one  substance.     This  fact  seems  to  me  to  leave  no  doubt  of 
the  nature  of  these  productions,  and  of  the  possibility  of  cicatri- 
zation in  ulcers  of  the  lungs.     It  further  proves,  that  a  bronchial 
tube  may  traverse  a  tubercle,  and  afterwards  a  tuberculous  exca- 
vation, without  being  destroyed  ;  a  case,  however,  as  we  have  al- 
ready observed,  which  is  extremely  rare.     Those  wrinkled  depres- 
sions, then,  on  the  exterior  surface  of  the  lungs,  are  not  themselves 
cicatrices,  but  the  consequence  of   true  cicatrization  in  the  in- 
terior of  the  lung. 

These  cicatrizations,  especially  when  complete  and  composed 
ot'  a  substance   analogous  to  other  natural  tissues,  produce  no 
42 


330  PHTHISIS    PULMONALIS. 

symptoms  whatever,  that  can  denote  their  existence.  I  have  only 
remarked  in  some  cases,  where  there  was  reason  to  believe  their 
presence,  that  the  respiration  was  less  distinctly  audible  in  the 
supposed  diseased  point.  In  such  instances  also,  where  there  is 
much  of  the  black  pulmonary  matter  intermixed,  and  still  more 
where  there  are  calcareous  concretions,  there  is  generally  a  slight 
degree  of  cough,  and  an  expectoration  of  mucus  which  is  very 
viscid,  semi-transparent,  and  marked  by  dark  dots. 

The  great  number  of  cases,  in  which  this  wrinkling  or  purs- 
ing of  the  surface  of  the  upper  lobes  has  been  met  with  in  the 
Parisian  hospitals  since  the  publication  of  the  first  edition  of  this 
work,  has  induced  some  physicians  to  maintain  that  they  do  not 
depend  on  an  internal  cicatrice.  There  can  be  no  doubt,  how- 
ever, of  this  being  the  fact,  in  the  cases  related  by  me ;  and  I 
have  never  yet  met  with  an  example  of  the  internal  cicatrization, 
unaccompanied  by  the  external  depression.  In  respect  of  the 
cases  in  which  a  slight  external  wrinkling  is  observed  without 
any  well-marked  cicatrice,  1  have  to  repeat,  that  it  requires  a 
good  deal  of  attention  to  distinguish  a  cellular  cicatrice  amid  a 
tissue  so  eminently  cellular  as  the  lungs.  In  cases  of  this  kind, 
as  in  all  others  which  require  application,  it  is  much  easier  not 
to  see  than  to  verify  the  fact.  It  is  indeed  true  that  these  exter- 
nal depressions  are  very  numerous,  being  met  with  in  almost 
every  case  of  phthisis,  and  in  a  fourth  part,  perhaps,  of  indivi- 
duals dead  of  other  diseases.  But  we  need  not  be  surprised  at 
this  frequency  ;  since  we  know  that  from  a  fourth  to  a  fifth  part  of 
the  inhabitants  of  Paris  die  of  phthisis.  Besides,  we  have  already 
shown,  that  this  disease  exhibits  frequently  successive  crops  of 
tubercles ;  and  it  is  probable  that  the  patient  who  at  last  falls  a 
victim  to  it,  may  have  got  the  better  of  several  previous  attacks. 
On  the  other  hand,  the  moderate  severity  of  the  general  symp- 
toms where  there  exists  only  one  or  two  tuberculous  masses,  of  a 
small  or  even  a  considerable  size,  (that  of  a  small  apple,  for  in- 
stance,) ought  to  make  us  believe  that  a  number  of  lesser-sized 
tubercles  may  form,  acquire  the  size  of  a  hazle-nut,  soften,  dis- 
charge their  contents  into  the  bronchi,  and  finally  cicatrize,  with- 
out obvious  derangement  of  the  general  health.  There  is  nothing 
more  common  than  to  find,  in  the  bodies  of  persons  dead  of  dis- 
eases unconnected  with  the  chest,  a  small  number  of  tubercles, 
sometimes  of  considerable  size,  and  some  of  them  softened  and 
excavated,  disseminated  through  the  lungs  in  other  respects  quite 
sound.  Nothing  having,  in  these  cases,  announced  the  existence 
of  tubercles,  I  see  no  reason  for  doubting  that  the  same  thing  may 
occur  in  persons  entirely  healthy*     In  instances  of  this  sort  the 

*  For  as  many  as  eight  or  ten  examples  of  cicatrization  of  the  lungs  after 
tubercles,  I  reler  the  reader  to  M.  Andral's   Clin.  Med.  t.  iii.  p.  382.     These 


PHTHISIS    PULMONALIS. 


331 


softening  of  the  tuberculous  matter,  and  its  excavation  by  the 
bronchi,  or  by  the  absorbents,  will  be  followed  by  a  cicatrice  of 
too  small  a  size,  in  general,  and  too  like  the  pulmonary  tissue, 
to  be  readily  and  at  once  distinguished,  especially  by  those  who 
proceed  to  the  examination  with  a  prejudiced  mind.  The  two 
following  cases  afford  remarkable  examples  of  this  species  of  cic- 
atrization. 

Case  XXII.  Ancient  cicatrice  in  the  lungs  in  a  patient  who 
died  of  pleurisy  and  peritonitis. — A  man,  aged  sixty-five,  came 
into  the  hospital  on  the  29th  of  November,  affected  with  slight 
pulmonary  disorder,  chiefly  marked  by  dyspnoea,  to  which  he 
had  been  long  subject,  and  which  he  considered  as  asthma.  Per- 
cussion afforded  no  result,  owing  to  the  excessive  fatness  of  the 
individual ;  only  the  chest  appeared  to  sound  somewhat  less  be- 
low the  right  clavicle.  Respiration  was  inaudible  over  the  whole 
of  the  right  side,  but  was  puerile  on  the  left.  From  these  re- 
sults, I  considered  this  person  as  affected  with  a  latent  pleurisy 
of  the  right  side  of  the  chest.  Five  days  after  this,  there  was 
observed  slight  oedema  of  the  right  side  of  the  chest;  and  on 
applying  the  stethoscope  to  the  back,  respiration  was  somewhat 
perceptible  along  the  edge  of  the  spine  on  the  right  side,  though 
less  so  than  on  the  left.  There  was  very  little  cough,  and 
scarcely  any  expectoration.  After  a  few  days  the  oppression  be- 
came less,  and  we  began  to  hear  the  sound  of  respiration,  in  a 
slight  degree,  below  the  right  clavicle ;  and  aegophony  was  per- 
ceptible in  the  same  spot  for  a  few  days.  On  the  11th  of  De- 
cember the  chest  sounded  still  better  in  this  point,  and  respiration 
became  as  distinct  as  on  the  opposite  side,  but  was  not  percepti- 
ble lower  than  the  third  rib :  it  was  also  sufficiently  distinct  be- 
tween the  spine  and  scapula.  At  this  time  the  patient  expec- 
torated some  opaque,  yellow,  puriform  sputa.     The    symptoms 

cases  are  still  more  striking  than  those  recorded  in  the  text;  and,  together  with 
them,  put  the  fact  of  the  healing  of  individual  tuberculous  excavations,  at  least, 
beyond  all  question.  At  the  same  time,  I  am  of  opinion,  that  M.  Laennec  has 
exaggerated  the  frequency  of  cases  of  this  kind  ;  and  has  considered  certain 
appearances  as  signs  of  cicatrization,  which  were  probably  owing  to  other  causes. 
I  think  it  not  unlikely  that  simple  pneumonia,  or  pleuro-pneumonia,  and  indeed 
other  and  less  severe  diseases,  may  give  rise  to  many  of  the  slighter  deviations 
from  the  natural  structure  considered  by  him  as  tuberculous  cicatrices.  On  this 
point  the  following  statement  of  M.  Louis  is  important:  "I  have  not  met  with 
any  of  those  masses  of  condensed  cellular  substance  in  the  upper  lobes,  in 
which  bronchial  tubes,  more  or  less  enlarged,  are  seen  to  terminate,  and  which 
M.  Laennec  looks  upon  as  cicatrices  of  tuberculous  excavations.  The  depres- 
sions on  the  surface  of  the  same  parts,  around  which  the  substance  of  the  lung 
is  found  pursed  or  wrinkled,  have  not  appeared  to  me  to  be  owing  to  any  de- 
terminate lesion. — I  have  frequently  observed  them  in  cases  where  the  lung 
was  quite  sound,  or  only  slightly  indurated  to  a  small  depth  immediately  be- 
neath the  pleura.  I  have  also  found  them  sometimes  when  there  existed  in  tho 
summit  of  the  upper  lobe,  tubercles  still  unsoftcned,  small  excavations,  or  bony 
concretions." — Recherches,  p.  36. —  Trunsl. 


332  PHTHISIS    PULM0NAL1S. 

continued  much  the  same  until  the  middle  of  February,  when  he 
died,  apparently  from  an  attack  of  peritonitis. 

Dissection  twenty-four  hours  after  death. — The  cavity  of  the 
right  pleura  contained  about  a  pint  of  yellow  and  somewhat 
turbid  serum.  The  lung  of  the  same  side  adhered  to  the  dia- 
phragm and  posterior  part  of  the  chest,  by  a  strong,  short,  and 
well-organized  cellular  tissue.  On  the  anterior  surface  of  the 
lung,  about  its  middle,  there  was  a  false  membrane,  about  the 
size  of  the  palm  of  the  hand,  soft,  opaque,  yellowish,  of  a  con- 
sistence inferior  to  that  of  half-concrete  albumen,  and  appearing, 
at  first  sight,  like  the  matter  of  thick  puriform  sputa.  This 
patch  was  traversed  by  numerous  blood-vessels,  and  adhered  to 
the  costal  pleura  by  a  lamina  of  greater  consistence,  also  very 
vascular,  and  approaching  more  to  the  texture  of  cellular  mem- 
brane. Above  and  behind,  another  firm  albuminous  crust,  yel- 
low and  vascular,  attached  the  lungs  to  the  pleura.  The  sub- 
stance of  the  lung  was  sufficiently  crepitous  in  the  upper  half, 
although  somewhat  injected  with  a  bloody  serum.  Its  lower 
portions  were  more  compact,  of  a  deeper  red,  and  in  spots  some- 
what granular  on  incision ;  it  was  also  gorged  with  bloody 
serum,  and  less  crepitous  than  the  upper  parts.  The  left  lung 
adhered  to  the  pleura,  at  its  summit,  by  means  of  old  cellular 
attachments.  In  this  point  there  was  an  irregular  depression,  in 
the  centre  of  which  lay  a  small  ossification.  From  this  spot 
could  be  traced  into  the  substance  of  the  lung,  a  band  of  very 
white  cellular  tissue,  very  dense,  .yet  scarcely  amounting  to  the 
consistence  of  a  membrane.  This  band  was  about  an  inch  long, 
six  lines  broad,  and  three  or  four  thick.  Its  white  color  formed 
a  striking  contrast  with  the  natural  pulmonary  tissue.  Some 
bronchial  tubes  of  the  size  of  a  crow-quill,  or  larger,  terminated 
and  became  lost  in  this  band, — which  an  accidental  circumstance 
prevented  me  from  examining  more  minutely.  The  pulmonary 
substance  was  crepitous  throughout,  and  there  were  no  tubercles 
in  either  lung.  The  pericardium  contained  a  few  ounces  of 
limpid  serum,  and  the  heart  was  larger  than  the  hand  of  the 
individual.  The  walls  of  the  left  ventricle  were  about  eight 
lines  thick  at  the  origin  of  the  columnar,  and  six  lines  at  the  base, 
and  were  very  firm ;  the  cavity  of  the  ventricle  was  very  small.* 
The  right  ventricle  seemed  small,  and  its  parietes  were  of  natural 
thickness.  The  peritoneum  was  inflamed,  and  its  cavity  contained 
coagulated  lymph  and  serum. 

Case  XXIII.  Ancient  fibrocartilaginous  cicatrice  of  the 
lung  in  a  person  who  died  of  pneumonia. — A  man,  aged  sixty- 

This  well-marked  case  of  hypertrophy  had  not  born  suspected,  although 
the  heart  had  been  examined  several  times  by  the  stethoscope,  owing  to  the  ex- 
istence of  the  disease  in  the  lungs,  which  masked  the  symptoms.— Author. 


PHTHISIS    PULMONALIS. 


333 


two,  had  been  affected  five  years  with  an  habitual  cough,  but 
was  otherwise  of  a  good  constitution.  On  the  4th  of  April,  1818, 
he  was  suddenly  seized  with  acute  pain  in  the  lower  part  of  the 
left  chest,  which  soon  extended  over  nearly  the  whole  side, 
attended  by  difficult  and  painful  respiration,  and  inability  to  lie 
on  the  affected  part.  He  came  into  the  hospital  on  the  8th,  and 
exhibited  the  following  symptoms : — general  paleness,  left  cheek 
slightly  colored ;  lips  bluish ;  external  jugulars  swelled ;  pulse 
weak  and  frequent ;  breathing  short,  loud,  and  painful,  and  with 
open  mouth ;  cough  not  very  frequent  and  by  fits ;  expectora- 
tion scanty,  the  sputa  very  viscid,  frothy,  semi-transparent,  and 
intermixed  with  some  yellow  and  opaque  matters.  Percussion 
yielded  a  very  good  sound  on  the  right  side,  but  was  not  so  good 
on  the  left.  Respiration  was  quite  inaudible  in  almost  the  whole 
extent  of  the  left  side,  whilst  on  the  right  it  was  strong,  and 
attended  by  a  rhonchus  and  sort  of  hissing  sound.  The  pulsa- 
tions of  the  heart  were  regular.  The  contraction  of  the  ventri- 
cles yielded  a  very  dull  sound,  and  a  slight  impulse ;  that  of  the 
auricles  was  sonorous  and  heard  distinctly  below  the  clavicles. 
The  paleness  of  this  man,  and  the  cough  to  which  he  had  been 
so  long  subject,  leading  to  the  suspicion  of  tubercles,  we  exam- 
ined the  chest  in  several  points  with  the  view  of  discovering  pec- 
toriloquy, but  did  not  find  it :  we  did  not  examine  with  this  view, 
however,  the  top  of  the  shoulder,  on  account  of  the  patient's 
weakness.  From  these  results  the  following  diagnostic  was  (pro- 
visionally) made :  Pleuro-pneumonia  of  the  left  side.  Tuber- 
cles 1  Slight  dilatation  of  the  heart  ?  This  man  died  the  fol- 
lowing night. 

Dissection  thirty-six  hours  after  death. — The  left  cavity  of 
the  chest  was  larger  than  the  right.  The  right  lung  adhered, 
throughout,  to  the  pleura  by  means  of  ancient  attachments.  On 
its  upper  part  there  was  a  fibro-cartilaginous  mass,  covering  the 
lung  somewhat  like  a  cap.  It  was  three  lines  in  thickness  in  its 
centre,  and  formed  in  this  point,  the  medium  of  adhesion  to  the 
ribs.  At  the  level  of  the  second  rib,  it  insensibly  vanished  in 
the  pleura.  The  substance  of  the  lung  was  very  crepitous  ante- 
riorly, but  little  so  posteriorly,  in  which  part  it  was  flaccid  and 
much  injected  by  very  fluid  blood.  This  lung  was  also  marbled 
by  a  great  number  of  spots  formed  by  black  pulmonary  matter. 
In  the  same  lobe,  included  in  the  pulmonary  tissue,  and  strongly 
adhering  to  it  by  continuity  of  substance,  there  was  found  a 
fibro-cartilaginous  mass  of  a  similar  kind,  of  the  size  of  a  walnut, 
and  of  an  irregular  conic  shape.  This  mass  was  of  a  brilliant 
white  color,  and  opaque,  and  formed  a  striking  contrast  with 
the  surrounding  pulmonary  tissue,  which  contained  an  unusual 
quantity  of  the  black  matter.     That  part  of  the  pulmonary  sub- 


334  PHTHISIS    PULMONALIS. 

stance  interposed  between  it  and  the  superficial  mass,  about  two 
lines  in  thickness,  was  quite  black,  and  destitute  of  air,  although 
its  natural  texture  was  very  perceptible.  This  fibro-cartilaginous 
mass,  when  cut  into,  presented  all  the  characters  of  a  pulmonary 
cicatrice.  In  one  or  two  small  portions  of  it,  the  texture  was 
softer,  somewhat  cellular,  and  charged  with  a  transparent  serum. 
Several  bronchial  tabes  terminated  and  were  obliterated  in  its  sub- 
stance. Two,  especially,  which  terminated  in  it,  in  forming  a 
cul-de-sac,  were  of  the  size  of  a  goose-quill.  One  of  these,  after 
forming  a  cul-de-sac,  of  a  diameter  of  two  lines,  became  all  at 
once  contracted  to  a  size  scarcely  equal  to  a  crow-quill,  on  enter- 
ing the  tumor,  into  which  it  could  be  traced  half-an-inch.  In 
this  tract,  however,  its  cavity  was  entirely  obliterated,  and  it 
resembled  in  color  and  texture  the  tumor,  from  which  it 
was  only  distinguished  by  the  direction  of  its  fibres,  or  by  a 
slight  shade  of  color  which  pointed  out  both  its  coats  and 
its  obliterated  canal.  In  the  superior  lobe  of  the  left  lung,  there 
was  a  small  cavity  capable  of  containing  a  filbert,  lined  by  a  fine 
semi-transparent  membrane,  of  a  semi-cartilaginous  consistence, 
and  through  which  the  black  pulmonary  matter  could  be  distin- 
guished. This  excavation  contained  a  small  quantity  of  tubercu- 
lous matter,  friable,  and  of  the  consistence  of  soft  cheese.  The 
pulmonary  tissue  amid  which  it  was  placed  was  perfectly  sound 
and  crepitous.  Near  the  origin  of  the  bronchi  was  observed  a 
single  tubercle  of  the  size  of  a  barley-corn,  softened  to  the  con- 
sistence of  soft  cheese,  and  surrounded  by  a  dense  membrane, 
greyish  and  semi-transparent,  of  the  nature  of  the  bodies  termed 
imperfect  cartilages.  In  its  anterior  quarter,  the  left  lung  was 
crepitous,  but  the  remaining  part  was  of  the  consistence  of  Jiver. 
The  base  of  this  lung  adhered  to  the  diaphragm  by  its  whole 
border ;  and  in  its  centre  there  was  a  patch  of  concrete  lymph  of 
the  consistence  of  white  of  egg.  It  was  easily  separated  from 
the  pleura  of  the  lungs,  which  appeared  redder  than  natural. 
The  inner  surface  of  the  pericardium,  where  this  membrane  is 
attached  to  the  diaphragm,  was  of  an  intense  puncturated  red  for 
the  space  of  a  square  inch.  The  pericardium  contained  about 
two  ounces  of  a  very  bloody  serum,  and  two  or  three  flakes  of  half- 
concrete  lymph.  The  heart  was  larger  than  the  hand  of  the 
subject,  and  exhibited  on  its  anterior  surface  a  white  spot  of  a 
cellular  character,  of  the  size  of  the  nail.  The  right  ventricle 
was  larger  than  natural,  of  the  usual  thickness,  but  yellowish 
and  of  a  flaccid  texture.  The  left  ventricle  was  evidently  dilated, 
and  it  was  only  four  or  five  lines  thick  ;  its  texture  was  soft  and 
pale  like  the  right. 

The  foregoing  cases  prove,  I  think,  that  tubercles  in  the  lungs 
are  not  in  every  case  a  necessary  and  inevitable  cause  of  death  ; 


PHTHISIS    PULMONALIS. 


335 


and  that  a  cure  may  take  place  in  two  different  ways,  after  the 
formation  of  an  ulcerous  excavation  :    first,  by  the  cavity  be- 
coming invested  by  a  new  membrane  analogous  to  some  of  the 
textures  of  the  healthy  body  ;  and  secondly,  by  the  obliteration 
of  the  excavation  by  means  of  a  cicatrix,  more  or  less  complete, 
consisting  of  cellular,  fibrous,  and  cartilaginous   substance.     The 
identity  of  the  excavations  observed  in  the  17th,  18th,  19th,  21st, 
and   22nd  cases,  leaves  no  question  that  they  had  one  and  the 
same  origin,  namely,  the  softening  and  discharge  of  the  tubercu- 
lous matter  originally  contained  in  them.     The  17th  case  may  be 
considered  as  affording  an  example  of  a  perfect  cure,  since  no 
more  tubercles  existed  in  the  lungs.     The  same  may  be  said  of 
the  23rd, — inasmuch  as  there  was  only  one  very  small  tubercle 
in  the  lungs.     The  subjects  of  the  18th,  19th,  and  21st  cases 
would,  no  doubt,  have  had  relapses  of  their   disease,  since  their 
lungs  all  contained  tubercles  more  or  less  advanced,  and  which 
must  necessarily  have  been  eventually  developed.     This  develop- 
ment, however,  might  have  been  remote  ;    since   it   has   been 
truly  shown   by   M.  Bayle,   that   crude,  and  still  more,  miliary 
tubercles,  continue  to  exist  for  a  great  many  years  without  ma- 
terially affecting  the  general  health.     Were  it  in  our  power  to 
ascertain  the  previous  history  of  such  cases  as  exhibit  these  car- 
tilaginous excavations  and  cicatrizations  in  the  lungs  after  death, 
we  should,  in  all  probability,  find  that  the  patients  had  been  sub- 
ject to  a  long-continued  cough,  and  severe  catarrh,  or  even  to  a 
disease  considered  at  the  time  as  true  consumption,  and  which 
had  been  very  unexpectedly  cured.*     These  morbid  appearances, 
at  least  sufficiently  explain  the  fact  of  the  seemingly  intermittent 
character  of  certain  cases  of  consumption,  and  the  extraordinary 
cure  of  others. 

These  pulmonary  fistulae  and  cicatrices  are  very  common,  as 
any  one  will  be  convinced  who  practices  morbid  dissections  in  an 
hospital  for  any  length  of  time.  I  have  only  mentioned  a  few  of 
those  I  have  met  with  lately  ;  and,  indeed,  it  is  only  lately  that 
I  have  paid  any  minute  attention  to  such  appearances.  I  had, 
however,  frequently  met  with  them  long  before,  and  have,  indeed, 
partly  described  them  in  another  place.f  They  are  very  various 
in  their  appearance  ;  and  it  would  seem  that  it  is  especially  by 
the  production  of  this  adventitious  cartilaginous  tissue  that  na- 
ture attempts  a  cure  of  tuberculous  excavations.  With  this  end 
she  seems  occasionally  to  throw  out  a  superabundance  of  it ;  as 
the  exterior  portion  of  the  lung  is  sometimes  coated  with  it,  as  in 

*  I  am  aware  that  phthisis  may  he  closely  assimilated  hy  a  common  catarrh. 
I  shall  notice  a  case  of  this  kind  hereafter,  (the  only  one  I  have  ever  met  with,) 
and  M.  Bayle  details  two  in  his  work,  viz.  cases  48  and  49. — Author. 

t  Diet,  des  Scienc.  Med.  Art.  Cart.  Accident. 


336  PHTHISIS    PULMONALIS. 

one  of  the  cases  already  detailed.  On  other  occasions  the  carti- 
laginous walls  of  the  cavity  are  observed  of  very  unequal  thick- 
ness,— as  thick  in  some  places  as  half-an-inch  or  an  inch, — as  if 
the  remedial  powers  of  nature  were  undetermined  whether  to 
form  a  perfect  cicatrix  or  only  a  fistula. 

Very  frequently  the  production  of  these  accidental  cartilages 
is  accompanied  or  followed  by  a  copious  formation  of  phosphate 
of  lime  in  their  vicinity.  It  is,  however,  uncommon  for  these 
fistulous  cysts  to  ossify,  although  I  have  mentioned  an  instance 
of  the  kind  ;  but  they  frequently  contain  the  salt  just  named  in 
an  earthy  form,  and  humid.  Still  more  frequently,  the  substance 
of  the  lungs  is  infiltrated  with  the  same  (more  or  less  dry,  and 
mixed  with  black  matter)  in  the  points  formerly  occupied  by 
tubercles.  Sometimes  we  find  a  few  small  tubercles,  the  product 
of  a  previous  eruption,  some  of  which  are  crude  or  in  different 
degrees  of  softening,  others  more  or  less  completely  destroyed  by 
absorption,  and  replaced  by  the  earthy  phosphate,  which  would 
seem  to  have  been  deposited  in  proportion  as  the  tuberculous 
matter  was  absorbed.* 

The  merely  temporary  cure  of  many  phthisical  cases  is  readily 
explained,  as  above  remarked,  by  the  cicatrization  of  a  softened 
tubercle,  and  by  the  eventual  softening  of  others  which  were  only 
in  their  first  stage  at  the  period  of  the  cicatrization  of  the  first. 
For  example,  we  can  easily  fancy  that  the  subject  of  Case  XXI, 
detailed  above,  had  he  not  been  carried  off  by  another  disease, 
might,  after  the  perfect  cicatrization  of  the  cavity  in  the  right 
lung,  have  enjoyed  tolerable  health  for  several  years,  until  the 
ultimate  maturation  of  the  miliary  tubercles,  which,  sooner  or 
later,  must  inevitably  have  induced  phthisis. 

I  had  occasion  in  the  year  1814  to  see  a  remarkable  instance 
of  this  temporary  cure  of  consumption. 

Case  XXIV. — M.  Recamier  and  myself  were  consulted  by  a 
young  lady  who  had  every  symptom  of  pulmonary  consump- 
tion, such  as  frequent  cough,  purulent  expectoration,  much  ema- 
ciation, hectic  fever,  and  night  sweats.  Several  of  the  lymphatic 
glands  of  the  neck  were  swollen,  and  for  a  few  days  she  had 
been  affected  with  very  severe  diarrhosa.  Astringents,  sulphur 
baths,  and  asses'  milk  were  prescribed ;  and  were  followed  by 

*  It  is  the  observation  of  this  fact  that  has  led  M.  Andral  to  admit  two  termi- 
nations of  the  solid  tubercle — the  purulent  and  cretaceous.  This  last  transfor- 
mation is  effected,  he  says,  by  the  subtraction  of  the  animal  matter  which  con- 
stitutes the  greater  portion  of  tubercle,  and  by  an  augmentation  of  the  calca- 
reous secretion.  In  support  of  these  views  he  cites  the  analysis  by  M.  Thenard 
of  the  matter  of  crude  tubercles,  and  of  tubercles  which  had  undergone  the  cal- 
careous transformation.  The  first  gave — animal  matters,  98.  lf> ;  miniate  ol 
soda,  phosphate  and  carbonate  of  lime,  1.  85;  oxide  of  iron,  a  trace  ; — the  sec- 
ond gave — animal  matters,  3  ;  saline  matters,  96.' — (Precis.  d'Anat.  1'atk.  t.  i.  p. 
417.)— (JIT.  L.) 


PHTHISIS    PULMONALIS.  337 

such  success  that,  in  the  course  of  two  months,  her  strength,  flesh, 
and  color,  were  quite  restored,  the  cervical  glands  were  dimin- 
ished one-half,  and  in  short,  she  was  in  a  state  of  perfect  health. 
She  passed  the  winter  very  well,  but  in  April  the  cough  and  all 
the  other  phthisical  symptoms  returned,  and  she  died  in  the  end 
of  the  summer. 

Such  examples  of  a  perfect  though  only  temporary  cure  of 
consumption  are  rare :  but  it  is  by  no  means  unusual  to  find 
persons  affected  with  all  the  symptoms  of  this  disease  surviving 
for  many  years,  alternately  experiencing  imperfect  convalescences 
and  relapses  more  or  less  severe.  It  is  such  cases  M.  Bayle  had 
in  view  when  he  said  consumption  may  continue  forty  years. 
These  imperfect  cures  may,  I  think,  be  attributed  to  the  succes- 
sive softening  of  several  tubercles,  and  their  subsequent  conver- 
sion into  fistulse  ;  whilst  the  more  perfect,  though  still  temporary 
cures,  may  depend  on  the  formation  of  a  cicatrix.  The  results 
of  these  two  kinds  of  cure,  as  far  as  I  am  able  to  judge  from  the 
cases  I  have  met  with,  seem  to  me  to  be  the  following: — the 
cure  by  fistula?  usually  leaves  behind  it  a  chronic  catarrh,  more 
or  less  severe,  and  is  accompanied  by  an  expectoration  which  is 
sometimes  very  copious ;  cicatrization,  on  the  contrary,  produces 
no  other  inconvenience  than  a  dry  cough,  neither  frequent  nor 
severe.  Sometimes,  indeed,  there  is  no  cough,  especially  where 
the  texture  of  such  cicatrices  closely  resembles  that  of  other  na- 
tural tissues  in  the  animal  economy,  especially  the  cellular  or 
fibro-cartilaginous.  When,  however,  the  substance  of  the  cica- 
trice is  less  perfect  and  more  remote  from  the  healthy  tissues  of 
the  body,  and  when  it  is  impregnated  with  much  of  the  black 
pulmonary  matter,  as  in  Case  XXIII,  we  find  an  habitual  cough, 
either  dry  or  accompanied  by  a  mucous  expectoration,  and  ca- 
chectic condition  of  the  body,  even  after  the  complete  destruction 
of  the  tubercles. 

When  we  consider  that  the  formation  of  tubercles  in  the  lungs 
seems  usually  to  be  the  consequence  of  a  general  diathesis  ;  that 
these  are  frequently  found  contemporaneously  in  the  intestines, 
where  they  ultimately  occasion  ulceration  and  colliquative  diar- 
rhoea ;  and  that,  in  some  cases,  also,  they  exist  in  the  lymphatic 
glands,  the  prostate,  the  testicles,  the  muscles,  bones,  &c. ;  we 
must  be  led  to  believe  the  most  perfect  cure  that  can  take  place 
in  consumption  as  merely  temporary.  Admitting,  however,  the 
justness  of  this  conclusion  in  those  extreme  cases  of  tuberculous 
diathesis,  (which,  after  all,  are  but  rare  when  compared  with  the 
vast  number  of  consumptions,)  we  are  still  entitled  to  hope  for 
the  cure  of  many  cases  of  phthisis,  or  at  least,  for  such  a  suspen- 
sion of  their  symptoms  as  may  be  deemed  almost  equal  to  a  cure, 
as  the  individuals  may  enjoy  such  a  state  of  health,  as  may  en- 
43 


338  PHTHISIS    PULMONALIS. 

able  them  to  fulfil  all  the  duties  of  civil  life,  for  several  years,  or 
until  a  fresh  development  of  tubercles  produces  a  fresh  and 
final  seizure.  It  is  further  worthy  of  remark,  that,  although  in 
the  majority  of  the  subjects  in  which  I  have  observed  these 
fistula?  and  cicatrices,  the  lungs  contained  tubercles  in  different 
stages  of  their  progress,  and,  consequently,  a  certain  though  per- 
haps remote  cause  of  a  return  of  the  disease,  still  I  have  found 
the  same  marks  of  a  cure  in  subjects  in  whom  there  were  no 
tubercles  whatever,  either  in  the  lungs  or  in  any  other  organs. 
Cases  XVII  and  XXIII  afford  examples  of  this  fact.  In  such 
instances  it  may  be  supposed,  perhaps,  that  the  excavations  had 
been  the  product  of  simple  inflammation  of  the  pulmonary  tissue, 
and  not  of  tubercular  degeneration.  Such  a  supposition  is,  how- 
ever, quite  gratuitous.  Those  accustomed  to  much  morbid  dis- 
section have  almost  daily  experience  of  the  formation  of  these  car- 
tilaginous membranes  on  the  surface  of  tuberculous  excavations ; 
while  the  collection  of  pus,  or  true  abscess  of  the  substance  of 
the  lungs,  is  so  extremely  rare  (as  we  have  already  seen,  when 
treating  of  pneumonia)  as  to  be  justly  esteemed  one  of  the  most 
extraordinary  appearances  in  morbid  anatomy,  and,  therefore, 
quite  inadequate  to  account  for  an  occurrence  so  common  as  that 
of  fistulae  and  cicatrization  of  the  lungs. 

These  considerations  ought  to  induce  us  still  to  entertain  some 
hope  in  those  cases  of  consumption  wherein  we  have  reason  to 
believe,  from  the  result  of  percussion  and  of  our  explorations 
with  the  stethoscope,  that  the  greater  portion  of  the  lungs  re- 
mains still  permeable  to  the  air.  Although  we  are,  therefore, 
certain,  that  a  subject  that  is  pectoriloquous  has  an  ulcerated  ca- 
vity in  the  lungs,  we  are  not,  on  this  account,  equally  certain 
that  this  will  prove  the  cause  of  death.  We  may  even  be  justified 
in  believing  that  a  case,  wherein  all  the  ordinary  symptoms  of 
consumption  exist  together  with  pectoriloquy ,  is  more  favorable 
than  one  in  which  they  exist  without  this  peculiar  phenomenon  ; 
since,  in  the  first  case,  we  may  attribute  the  symptoms  to  the 
efforts  of  nature  in  maturing  and  evacuating  the  tuberculous 
matter,  and  may  hope  for  their  cessation  when  this  is  effected, 
provided  the  greater  portion  of  the  lungs  is  in  other  respects 
healthy  ;  while,  in  the  second  case,  we  must  imagine  that  the  tu- 
bercles are  very  numerous,  since  they  produce  such  violent  gene- 
ral effects  previous  to  the  period  of  their  softening,  and  that,  there- 
fore, they  will,  in  all  probability,  occasion  death  before  the  epoch 
of  possible  cure  arrives. 

I  regret  that  it  was  not  in  my  power  to  lay  before  the  reader 
any  account  of  the  diseases  which  had  produced  the  cicatrices  or 
fistulse  observed  in  the  subjects  of  the  17th,  18th,  19th,  21st. 


PHTHISIS     PULMONALIS. 


339 


22nd,  and  23rd  cases ;  but  I    am  enabled  to  detail   two  others, 
which,  as  well  as  21,  seem  to  be  a  counterpart  of  the  former. 

Case  XXV.     Tuberculous  phthisis  cured. — An  English  gen- 
tleman, aged  thirty-six,  detained  in  Paris  as  a  prisoner  of  war,  in 
September,    1813,  had  an  attack  of  haemoptysis,  followed  by  a 
cough,  at   first  dry,  but,  in  the  course  of  a  few  weeks,  accompa- 
nied   by   a  purulent  expectoration.      To   these  symptoms  were 
added  a  well-marked  hectic,  considerable  dyspnoea,  copious  night 
sweats,  emaciation,  and  great  debility.     The  chest  sounded  well 
every  where,  except  under  the  right  clavicle,  and  in  the  axilla  of 
the  same  side.  The  haemoptysis  returned  in  a  slight  degree,  now 
and  then,  and  in  December  he  had  diarrhcea,  which  was  with  dif- 
ficulty checked  by  astringents.     In  the  beginning  of  January  he 
was  so  much  reduced,  that  both   M.  Halle   and  Bayle   agreed 
with  me  in  opinion,  that  his  death   might  be  daily   looked   for. 
On  the  15th  of  January,  during  a   severe   fit  of  coughing,   and 
after  bringing  up  some  blood,  he  expectorated  a  solid  mass,  of  the 
size  of  a  filbert,  which,  on  examination,  I  found  to  be  evidently  a 
tubercle  in  the  second  stage,   surrounded,  apparently,  by  a  por- 
tion of  the  pulmonary  tissue,  such  as  has  been  already  described 
as  impregnated  with  grey  tubercular  matter  in  the  first  stage, 
often  met  with  around  these  bodies   when   large.     This    patient 
remained  in  the  same  degree  of  extreme  emaciation  and  debility 
all  January,  being  expected    to   die  daily ;  but  in   the  beginning 
of  February  the  perspirations  and  diarrhoea  ceased  spontaneously, 
the  expectoration  sensibly  diminished,  and  the  pulse  which  had 
been  constantly  as  high  as  120,  fell  to  90.     In  a  few  days  the  ap- 
petite returned,  the  patient  began  to  move  about  in  his  room,  his 
emaciation  became  less,  and,  against  the  end  of  the  month,  his 
convalescence  was  evident.     In  the  beginning  of  April  he  was 
perfectly  recovered ;  and  his  health  has  continued  good  ever  since, 
without  even  the  least  cough,  and  without  his  being  at  all  particu- 
larly guarded  in  his  climate  or  regimen.     In   1818  this  patient 
again  consulted  me  for  a  different  complaint,  and  I  took  the  oppor- 
tunity of  examining  his  chest  by  means  of  the  stethoscope.     The 
only  thing  I  could  detect,  was  the  comparative  indistinctness  of 
respiration  in  the  superior  portion  of  the  right  lung,  as  low  as  the 
third  rib.     This  part,  however,  sounded  as  well  on  percussion  as 
the  opposite  side,  and   there  was  no   pectoriloquy.     From    these 
circumstances,  I  am  of  opinion,  that  the  excavation  which  con- 
tained the  expectorated  tubercle,  must  have  been   replaced  by  a 
cellular  or  fibro-cartilaginous  cicatrice ;  and  as  the  total  absence 
of  cough,  dyspnoea,  and  expectoration,  for  so  long  a  period,  forbids 
the  supposition  of  the  existence  of  others  in  the  lungs,  I  think  we 
have  a  right  to  consider  this  patient  as  perfectly  cured.     In  1824, 
this  gentleman  was  examined  at  Rome  by  Dr.  Clark,  an  English 


340  PHTHISIS     PULMONALIS. 

physician,  who  practises  there  with  great  distinction,  and  who 
recognized  him  as  the  subject  of  the  case  just  detailed.  I  saw 
him  also  the  same  year,  and  found  him  precisely  in  the  same  state 
as  in  1818.* 

Case  XXVI.  Phthisis  pulmonalis  cured. — This  case  is  de- 
tailed in  M.  Bayle's  treatise,  (see  Case  LIV,)  and  is  that  of  a 
gentleman  who,  after  having  experienced  all  the  symptoms  of  con- 
sumption in  the  greatest  degree,  perfectly  recovered  by  change  of 
air,  and  living  by  the  sea-side.  As  both  M.  Bayle  and  myself  (for 
this  was  my  patient)  then  considered  the  cure  of  phthisis  impos- 
sible, we  considered  the  case  as  one  of  chronic  catarrh,  and  it  is 
so  entitled  in  M.  Bayle's  book.  Since  then  I  have  had  an  oppor- 
tunity of  satisfying  myself,  by  means  of  the  stethoscope,  that  our 
patient  had  had  more  than  a  mere  catarrh.  His  respiration  is 
quite  perfect  throughout  the  whole  chest,  except  at  the  top  of  the 
right  lung,  in  which  point  it  is  totally  wanting.  On  this  account, 
I  am  certain  that  this  portion  of  lung  had  been  the  seat  of  an  ul- 
cerous excavation,  and  that  this  had  been  replaced  by  a  complete 
and  solid  cicatrice.  The  health  of  this  gentleman  continues  good, 
although  he  has  often  occasion  to  speak  in  public.  He  has  some- 
times a  little  dry  cough,  on  the  change  of  tweather,  but  takes  cold 
very  seldom. 

I  here  terminate  what  I  had  to  say  respecting  the  possibility 
of  curing  phthisis  pulmonalis.  I  hope  the  importance  of  the 
subject  will  be  considered  as  sufficient  excuse  for  the  great  length 
of  my  dissertation.  In  regard  to  the  facts  adduced  by  me  in 
proof  of  the  curability  of  this  disease,  I  am  of  opinion  that  any 
attentive  observer  who  shall  choose  to  employ  the  same  means, 
viz.  auscultation  and  dissection,  will  frequently  meet  with  similar 
results.  My  experience  leads  me  to  deem  such  cases  to  be  ex- 
tremely common :  those  related  above  occurred  to  me  in  the 
course  of  some  months :  and  I  have  since  met  with  many  others. 
I  formerly  stated  that  I  had  often  previously  observed  similar 
appearances,  without  paying  much  attention  to  them ;  and  I 
may  here  add,  that,  in  the  natural  sciences,  when  our  attention  is 
not  particularly  directed  to  certain  objects,  we  may  meet  with 
them  every  day  without  observing  them.  A  gardener  is  seldom 
able  to  discriminate  the  tenth  part  of  the  plants  which  spring  on 
the  very  soil  which  he  is  cultivating ;  and  an  anatomist  may  know 
nothing  of  the  organic  changes  which  occur  in  the  human  body 
(though  he  sees  them  every  day)  while  engaged  in  tracing  the 

I  learn  from  Dr.  Clark,  who  is  now  resident  in  London,  and  whom  the 
English  reader  will  identify  as  the  distinguished  author  of  The  Influence  of  Cli- 
mate, that  Mr.  G.  is  still  living,  (1827,)  in  good  health.  Several  well-marked 
cases  of  expectorated  tubercle  arc  on  record.  A  very  remarkable  instance  is 
mentioned  in  the  Journ.  dc  Med.  t.  78,  for  March,  1789.  In  this  case  also,  the 
patient  recovered,  although  previously  on  the  brink  of  the  grave.— Transl. 


OCCASIONAL    CAUSES. 


241 


blood-vessels  or  nervous  filaments.  I  myself  can  bear  witness, 
from  personal  experience,  that  it  is  quite  possible  for  one  to 
forget,  in  part,  descriptive  anatomy,  although  in  the  daily  habit 
of  opening  dead  bodies.  To  conclude,  I  think  that  the  cure  of 
consumption,  where  the  lungs  are  not  completely  disorganized, 
ought  not  to  be  looked  upon  as  at  all  impossible,  in  reference  either 
to  the  nature  of  the  disease,  or  of  the  organ  affected.  The  pul- 
monary tubercles  differ  in  no  respect  from  those  found  in  scro- 
phulous  glands  ;  and  we  know  that  the  softening  of  these  latter 
is  frequently  followed  by  a  complete  cure.  On  the  other  hand, 
the  destruction  of  a  part  of  the  substance  of  the  lungs  is  by  no 
means  necessarily  mortal,  since  we  know  that  even  wounds  of 
these  organs  are  frequently  cured,  notwithstanding  the  unfavor- 
able condition  with  which  they  are  necessarily  complicated  by 
the  perforation  of  the  walls  of  the  chest,  and  the  admission  of 
air  into  the  pleura. 

Sect.  IV. — Occasional  causes  of  phthisis. 

I  have  already  answered  in  the  negative  the  question  as  to 
whether  consumption  is  the  result  of  the  inflammation  of  any  of 
the  constituent  textures  of  the  lungs.  Cold  is  generally  admitted 
as  one  of  the  most  powerful  occasional  causes  of  phthisis ;  and  it 
is  certain  that  this  disease  is  extremely  common  in  the  north  of 
Europe  and  America.  It  is  to  be  remarked,  however,  on  the 
one  hand,  that  in  northern  countries  the  inhabitants  suffer  less 
frequently  from  cold  than  in  temperate  climates,  owing  to  the 
warmer  clothing  and  houses  of  the  former,  which  the  severity  of 
the  winter  obliges  them  to  adopt ;  and,  on  the  other  hand,  that 
the  complaint  is  very  rare  among  the  natives  of  high  mountain- 
ous countries,  particularly  the  Alps,  whose  winters  are  as  long 
and  severe  as  those  of  the  north  of  Europe.  The  disease  is  also 
very  common  in  temperate  countries,  as  in  France,  in  the  north 
of  Spain,  of  Italy,  and  Greece.  It  appears  to  be  somewhat  less 
frequent  in  the  most  southern  parts  of  Europe,  and  still  less  so 
in  the  countries  between  the  tropics.*     In  respect  of  the  last- 

*  The  calculations  made  respecting  the  relative  prevalence  of  phthisis  in  dif- 
ferent places,  have  hitherto  been  founded  entirely  on  the  disease  in  an  open 
form;  but  it  is  frequently  latent;  and  it  is  not  impossible  that  it  may  here- 
after be  found  that  it  is  more  frequently  manifest  in  cold  climates,  and  common- 
ly latent  in  warm. — Author. 

Although  not  without  voluminous  documents  relating  to  the  degree  of  preva- 
lence of  consumption  in  all  the  countries  in  Europe,  and  in  many  parts  of  Asia, 
Africa,  and  America,  I  think  I  may  venture  to  assert,  that  we  are  still  destitute 
of  data  sufficiently  accurate  and  extensive,  to  enable  us  to  come  to  such  conclu- 
sions on  this  point,  as  will  satisfy  a  philosophical  mind.  This  much,  I  think, 
appears  to  be  made  out — that  in  the  most  northern  parts  of  Europe,  particularly 
Russia,  and  yet  more  between  the  tropics,  the  disease  is  considerably  less  prcva- 


342  PHTHISIS     PULMONALIS. 

mentioned  countries,  however,  it  is  to  be  observed,  that  the  parts 
of  them  best  known  to  us,  are  on  the  sea  shore ;  and  we  shall  see 
presently  that  there  is  a  very  great  difference  in  this  respect  be- 
tween coasts  and  the  interior  of  countries .*     Too  light  clothing, 

lent  than  in  the  more  temperate  climates.  Rates  of  prevalence  for  the  different 
countries  of  Europe,  and  for  different  parts  of  the  same  country,  have  been 
drawn  out  by  many  authors,  and  are  to  be  met  with  in  most  recent  works  on 
phthisis ;  but  I  have  no  hesitation  in  stating,  that  they  are  very  little  entitled  to 
our  confidence  ■;— not  from  any  inaccuracy  or  incompetence  of  the  calculators, 
but  from  the  almost  insurmountable  difficulties  of  the  subject,  in  the  present 
extremely  imperfect  state  of  our  medico-statistical  knowledge.  One  thing,  at 
least,  is  certain,  that  the  disease  is  extremely  prevalent  in  every  part  of  Great 
Britain,  Germany,  France,  Italy,  Spain,  and  in  the  islands  and  on  all  the  coasts 
of  the  Mediterranean  sea.  Our  author  is  fond  of  considering  maritime  situations 
as  much  less  liable  to  the  disease  than  the  interior  of  countries ;  but  we  have 
no  positive  proof  of  this.  In  England,  at  least,  I  can  state,  from  a  long  resi- 
dence on  the  southern  coasts,  that  consumption  is  extremely  prevalent  there. — 
For  such  imperfect  documents  as  we  possess  on  this  most  important  subject,  I 
refer  to  the  authors  mentioned  in  a  former  note,  and  also  to  the  more  recent  works 
of  Sir  Alexander  Crichton  and  Dr.  James  Clark. —  Transl. 

*  Pulmonary  phthisis  has  been  found  in  almost  all  countries  ;  but  the  frequen- 
cy of  the  disease  is  far  from  being  the  same  in  all.  It  does  by  no  means  in- 
crease with  the  diminution  of  temperature.  Thus,  in  Sweden,  one  of  the  most 
northerly  parts  of  Europe,  and  particularly  in  the  capital  of  that  kingdom,  it 
has  been  calculated  that  out  of  1000  deaths  there  were  but  63  by  consumption, 
while  at  London,  in  the  same  number  of  deaths,  236  on  an  average  were  owing 
to  tubercles  in  the  lungs.  According  to  the  researches  of  Dr.  Crichton  on  this 
subject,  consumption  is  vastly  more  frequent  in  Great  Britain  than  in  the  north 
of  Russia. 

In  the  temperate  parts  of  Europe,  namely,  the  regions  lying  between  the 
45th  and  50th  degrees  of  latitude,  consumption  is  more  common  than  to  the 
north  of  50.  Thus  throughout  the  whole  of  Germariy,  and  especially  at  Berlin, 
Munich,  and  Vienna,  it  carries  off  more  people  than  at  St.  Petersburg  or  Stock- 
holm. At  London  and  Paris  it  is  still  more  common  ;  causing  more  than  one 
fifth  of  all  the  deaths  at  London,  and  nearly  the  same  at  Paris,  while  at  Vienna 
and  Munich,  the  proportion  is  about  a  tenth  or  an  eleventh,  and  at  Berlin  a 
fifteenth. 

In  the  south  of  Europe,  from  45  to  35  degrees,  consumption  is  a  common 
disease,  and  even  in  this  region  there  are  spots  where  it  is  more  frequent  than 
at  the  north.  Thus  it  has  been  calculated  that  it  occasions  one  fourth  of  the 
deaths  at  Marseilles,  one  sixth  at  Genoa,  and  one  eighth  at  Naples.  On  the 
other  hand,  at  Rome,  which  lies  in  nearly  the  same  latitude  with  Naples  but  in 
different  topographical  circumstances,  the  case  is  different ;  only  a  twentieth  of 
the  deaths  being  caused  by  consumption.  It  has  likewise  been  shown  that 
consumption  is  very  common  in  Spain  and  Portugal,  particularly  in  the  capitals 
of  those  countries.  English  physicians  have  assured  us  that  it  rages  on  the 
rock  of  Gibraltar  and  the  island  of  Malta  ;  and  it  is  now  admitted  that  it  is  very 
prevalent  throughout  the  whole  European  coast  of  the  Mediterranean.  The 
climate  of  this  coast  during  summer  has  so  fatal  an  effect  upon  the  lungs  that 
the  English  garrisons  in  this  region,  send  home  during  the  warm  season  such  of 
their  soldiers  as  are  affected  with  pulmonary  complaints. 

In  advancing  South  between  the  20th  and  10th  degrees  of  latitude,  we  still 
find  this  disorder  :  all  physicians  who  have  lived  in  the  West  Indies  declare  it 
to  be  frequent  there.  Dr.  Clarke  has  concluded  from  these  researches  that 
consumption  is  more  common  in  the  English  settlements  in  the  East  Indies  than 
any  other.  On  the  contrary,  the  minimum  of  the  disease  in  all  the  English 
settlements  is  in  the  East  Indies  and  the  Cape  of  Good  Hope.  Yet  we  must  not 
imagine  this  last  spot  to  be  exempt  from  it.  Bontius  in  his  ancient  work  on  the 
diseases  of  India,  does  not,  it  is  true,  even  name  pulmonary  consumption  among 
the  disorders  which  he  observed  in  that  country  :  the  same  silence  has  been  pre- 


OCCASIONAL    CAUSES. 


343 


or  the  impression  of  cold,  when  the  body  is  heated,  seems  in  our 
cities  to  be  the  occasional  cause  of  phthisis,  in  many  young 
women,  whose  disease  begins,  or  at  least  the  severer  symptoms 
of  it,  with  a  pulmonary  catarrh,  a  pneumony  or  pleurisy.*  In- 
dependently of  temperature,  locality  has  no  doubt  an  influence 
on  the  production  of  phthisis.  It  is,  for  example,  more  common 
in  large  cities  than  in  small  ones,  and  more  frequent  in  the  latter 
than  in  the  country.  The  ancients  had,  in  all  probability,  al- 
ready remarked  that  it  was  less  common  in  maritime  situations, 
since  they  recommended  sailing  to  their  phthisical  patients.  This 
circumstance,  which  had  been  too  long  overlooked,  has  of  late 
years  justly  attracted  the  attention  of  the  English  physicians,  and 
they  are  now  in  the  constant  habit  of  sending  their  consumptive 
invalids  to  Maderia.f     I  have  myself  paid  particular  attention  to 

served  by  Anncsley  in  his  great  work  upon  the  diseases  which  he  witnessed  in 
this  part  of  the  world :  but  Dr.  Conwell,  another  English  writer,  has  exe- 
cuted a  work  upon  this  subject  (ex  professo).  He  published  the  results  of  a 
certain  number  of  necropsies  of  phthisical  subjects  performed  by  him  in  the 
Indies,  some  of  them  European,  the  others  natives.  No  doubt  can  be  enter- 
tained therefore  of  the  existence  of  the  disease  at  Calcutta. 

In  the  twenty-three  autopsies  performed  by  Doct.  Conwell,  he  found  tuber- 
cles in  the  parenchyma  of  the  liver  once  only,  four  limes  in  the  mesenteric 
glands,  six  times  in  the  coats  of  the  intestines,  twice  in  the  peritoneum,  and 
once  in  the  pleura.  Twenty-one  times  he  found  the  intestines  ulcerated,  and 
once  only  were  they  found  free  from  lesion. 

Thus  it  seems  clear  that  in  a  country  where  whites  and  blacks  live  together 
in  great  numbers,  the  mortality  by  consumption  is  much  greater  among  the 
blacks. 

The  following  very  curious  statement  is  made  by  Dr.  Marshall  in  his  top- 
ography of  the  Island  of  Ceylon. 

EuropeanslMalays 
Total  of  deaths  in  1000  inhabitants  in  one  year.     142  36 

Death  by  consumption  in  1000  persons  during  )         fi     I        o 

one  year.  3 

Deaths  by  consumption  out  of  1000  miscella-  ?      4  a  ra 

neous  deaths,  )  I 

This  writer  also  states  that  in  the  Negroes  who  die  of  consumption,  tubercles 
in  other  organs  than  the  lungs  are  found  oftener  than  in  the  whites.  This  tu- 
berculous diathesis  is  strongly  marked  in  the  monkeys  brought  from  warm 
countries  who  die  in  our  menageries.  In  almost  all  these  animals  the  lungs  are 
found  rilled  with  tubercles;  but  they  are  also  found  in  many  other  organs,  par- 
ticularly the  spleen.  Pulmonary  phthisis  therefore  is  a  disease  found  in  all 
latitudes,  but  does  not,  as  is  generally  thought,  decrease  and  increase  in  inverse 
proportion  to  the  temperature.  In  a  country  where  the  temperature  is  con- 
stantly low  and  not  subject  to  sudden  changes,  the  disease  is  rare.  When  the 
temperature  is  very  high  and  the  varieties  neither  large  nor  frequent,  but  regu- 
lar, the  disease  is  also  rare.  On  the  other  hand,  the  disease  acquires  its  max- 
imum of  frequency  in  countries  subject  perpetually  to  great  and  irregular  varia- 
tions of  temperature. — Jin&ral. 

*  But  these  causes  give  rise  much  more  frequently  to  severe  catarrhs,  pneu- 
monies  and  pleurisies,  which  are  not  followed  by  the  tubercular  disease  ;  so  that 
as  I  have  formerly  observed,  we  may  conclude  that  phthisis,  when  it  follows 
the  diseases  just  mentioned,  has  been  merely  accelerated  by  them,  the  tubercles 
having  previously  existed. — Author. 

t  I  need  hardly  inform  the  reader  that  this  statement  is  overcharged.  Some 
patients  are  certainly  sent  to  Madeira  every  year;  but  the  number  is  by  no 
means  great ;— certainly  very  far  short  of  the  number  sent  to  the  south  of  France 


Caffrees 
49 

7 
146 


Indians 
45 

2.6 

59 


344  PHTHISIS    PULMONALIS. 

this  subject,  and  in  the  absence  of  exact  numerical  calculations, 
which  could  only  be  procured  with  much  time  and  labor,  1  am 
glad  to  be  able  to  lay  before  the  reader  some  materials  which  I 
have  obtained  from  a  great  number  of  medical  men,  who  are  at 
present  resident,  or  who  have  been  long  resident,  on  the  coast,  and 
which  must  be  considered  as  very  valuable,  although  possessing 
only  an  approximate  exactness.  Most  of  the  naval  surgeons 
whom  I  have  had  an  opportunity  of  conversing  with,  have  in- 
formed me  that  they  had  scarcely  ever  known  a  man  become 
phthisical  in  the  course  of  a  long  voyage,  and  that  they  had  fre- 
quently seen  sailors,  whose  chests  seemed  seriously  affected  at 
the  time  of  putting  to  sea,  return  perfectly  well,  or  with  their 
health  singularly  improved.*  On  the  south  coast  of  Bretagne 
the  proportion  of  deaths  from  phthisis  seems  to  be  about  one 
in  forty  ;  and  on  the  north  coast  of  the  same  province,  as  well  as 
on  that  of  Normandy,  it  is  only  one  in  twenty, — at  least  in  the 
country  and  small  towns.  In  Paris,  and  the  great  cities  in  the 
interior  of  France,  the  proportion  is  well  known  to  be  as  great 
as  one  in  four  or  five.f  The  disease  appears  more  frequent  on 
the  coasts  of  England  and  northern  parts  of  Europe  ;  and  seems 
also  to  be  more  prevalent,  ceteris  paribus,  on  the  shores  of  the 
Mediterranean,  than  on  those  of  the  main  ocean.  The  influence 
of  the  sea  air  appears  to  be  felt  only  a  small  distance  from  the 
coast,  and  is  greater  in  proportion  as  we  approach  this.  I  have 
myself  attended  carefully  to  this  point  of  medical  statistics, 
during  the  two  years  which  I  have  been  obliged  to  spend  in  the 
country,  on  account  of  ill  health,  since  the  publication  of  my 
first  edition.  During  this  time  I  resided  in  Bretagne,  on  the 
shores  of  the  bay  of  Douarnenez,  in  the  parish  in  which  the 
small  town  of  the  same  name  is  situated.  The  population  of 
this  parish  is  about  four  thousand,  and  the  ordinary  annual  mor- 
tality about  one  hundred  and  forty.  During  the  two  years  above 
mentioned,  I  only  saw  six  cases  of  phthisis,  of  which  number 
three  were  cured ;  and  from  the  information  I  received  on  the 
spot,  I  do  not  think  that  the  annual  mortality  from  this  disease 

and  Italy,  although  its  climate  is  certainly  very  superior  to  that  of  any  European 
country.  It  must  not  be  concealed,  however,  that  consumption  is  very  preva- 
lent at  Madeira.  For  all  the  valuable  information  we  possess  on  this  subject  I 
refer  the  reader  to  Dr.  Clark's  admirable  work  On  the  Influence  of  Climate. — 
Transl. 

*  My  own  experience  is  not  in  accordance  with  this  statement,  nor  is,  I  fear, 
that  of  most  English  naval  surgeons.  See  the  valuable  works  of  Blane,  Trotter, 
Johnson,  Burnett,  &c.  See  also  a  Thesis  by  Dr.  Sinclair.  "  De  impetu  maris 
Mediterranei,"  &c.  Edin.  1817.—  Transl. 

t  The  average  number  of  deaths  from  consumption  in  the  following  towns  in 
England,  viz.  Bristol,  London,  Warrington,  Chester,  Shrewsbury,  Plymouth, 
Ackworth,  and  Holy  Cross,  from  documents  given  in  Dr.  Woollcombe's  work, 
is  more  than  one  in  four.  Dr.  Young  says,  that  the  proportion  of  deaths  for  the 
whole  of  Great  Britain  is  one  fourth. —  Transl. 


OCCASIONAL    CAUSES. 


345 


can  be  rated  at  more  than  three  *  This  statement  is  the  more  re- 
markable, as  there  are  included  in  the  number  of  inhabitants 
above  mentioned,  above  six  hundred  seamen,  one  half  of  whom, 
at  least,  had  been  detained  for  several  years  prisoners  of  war  in 
England.f  A  great  number  of  these  men  had  for  several  years 
been  affected  with  constitutional  syphilis,  which  had  been  kept 
at  bay  by  a  repeated  palliative  treatment ;  and  although  we  have 
no  positive  proof  that  this  state  of  disorder  is  capable  of  causing 
phthisis,  it  is  well  known  that  it  is  so  considered  by  many  prac- 
titioners ;  and  it  is  even  probable  that  an  inveterate  syphilis  and 
the  treatment  generally  had  recourse  to  for  its  removal,  may  prove 
an  occasional  cause  of  it. 

Haemoptysis  is  commonly  regarded  as  one  of  the  most  fre- 
quent causes  of  consumption.  T  did  not  take  any  notice  of  this 
affection  when  considering  the  question  of  the  production  of  tu- 
bercles by  inflammation  ;  because  the  congestions  which  give  rise 
to  haemorrhage,  not  having  any  tendency  to  produce  pus,  I  do 
not  consider  them  as  being  truly  inflammations.  The  common 
opinion  on  this  point  has  no  further  foundation  than  what  is 
supplied  by  the  axoim — post  hoc  ergo  propter  hoc.  It  is  indeed 
true  that  the  first  symptom  of  an  alarming  kind  in  the  greater 
number  of  phthisical  patients  is  haemoptysis  ;  but  if  we  examine 
the  chest  at  this  time,  we  shall  frequently  detect  the  presence  of 
tubercles  in  the  lungs.  And  when  we  consider  this,  and  know 
that  the  haemorrhage  will  probably  return  again  and  again  in  the 
progress  of  the  disease,  we  are  justified  in  concluding  that  tu- 
bercles in  the  lungs  are  the  most  frequent  cause  of  haemoptysis. 
Indeed  it  is  easily  conceived  how  this  is  so  ;  since  these  foreign 
bodies,  in  their  development,  must  compress  and  irritate  the  pul- 
monary tissue,  like  the  thorn  of  Van  Helmont.  On  the  other 
hand,  we  have  no  positive  proof  that  haemoptysis,  by  itself,  is  ca- 
pable of  giving  rise  to  tubercles  ;  and,  indeed,  considered  anatom- 
ically, it  is  not  easy  to  conceive  how  it  could  do  so.  If  such  were 
the  case,  we  should  find  the  haemoptysical  engorgement  gradually 

*  I  cannot  agree  with  Laennec  as  to  the  much  smaller  proportion  of  consump- 
tive persons  which,  according  to  him,  are  to  he  found  on  the  sea  coasts.  The 
variations  of  temperature  which  are  greater  on  the  coasts  than  elsewhere,  and 
the  cold  and  damp  winds  which  abound  there,  are,  assuredly,  powerful  causes 
of  pulmonary  tubercles.  These  causes  must  at  least  promote  the  development 
of  tubercles  in  persons  who  have  already  a  tendency  that  way.  It  seems  to  me 
very  extraordinary,  thai  out  of  only  six  cases  of  consumption  which  came  under 
i lie  observation  of  Laennec  during  his  residence  on  the  shore  of  the  bay  of 
Douarnenez,  three  were  cured.  Did  not  his  admirable  talent  at  diagnosis  fail 
him  liere.  under  a  prepossession  in  favor  of  the  salutary  influence  of  the  sea  air 
upon  phthisis  ? — Andral.  ' 

t  No  such  observations  have  been  made  at  Brest,  which  is  only  seven  leagues 
from  Douarnenez,  and  the  population  of  which  consists  almost  exclusively  of 
seafaring  people.  On  the  contrary,  consumption  is  there  almost  as  frequent  as 
in  Paris.— (M.  L.) 

44 


346  PHTHISIS     PULMONALIS. 

transformed  into  miliary  tubercles  :  and  this  I  have  never  seen.* 
It  is,  moreover  worthy  of  remark,  that  a  haemoptysis  produced 
by  violence  as  by  a  blow  on  the  chest,  violent  running,  a  fit  of 
passion,  immoderate  exercise  of  the  voice,  &c.  is  most  commonly 
productive  of  no  further  consequences,  when  it  is  once  got  un- 
der ;f  whilst  phthisis  frequently  supervenes  immediately  to  a  hae- 

*  M.  Andral  gives  (Clin.  Med.  t.  iii.  p.  39)  a  case  which,  in  his  opinion,  proves 
the  possibility  of  this  transformation.  In  the  lungs  of  a  man  afflicted  with 
chronic  peritonitis,  and  who  had  latterly  been  subject  to  severe  haemoptysis, 
several  masses  of  pulmonary  apoplexy  were  found,  one  of  which  contained  a 
considerable  number  of  granulutions  of  a  yellowish  white,  having  all  the  characters 
of  incipient  miliary  tubercles;  others  consisted  of  a  more  fluid  matter,  resembling 
drops  of  pus.  The  latter  part  of  this  statement  and  the  yellowish  color  of  the 
solid  granulations  evidently  prove,  in  my  opinion,  that  what  M.  Andral  took 
for  incipient  tubercles,  were  of  long  standing  and  partially  softened.  It  is 
therefore  more  than  doubtful  that  they  were  developed  after  the  haemoptysical 
engorgement,  and  it  is  even  much  more  probable  that  they  constituted  its  occa- 
sional cause. — (M.  L.) 

1  accept  this  criticism, 'and  it  seems  to  me  really  very  difficult  to  decide 
whether  the  tuberculous  granulations  discovered  by  me  as  above  described  were 
anterior  or  subsequent  to  the  formation  of  the  engorgement.  Since  I  published 
that  observation,  I  have  not  met  with  any  fact  to  demonstrate  that  the  tubercu- 
lous matter  can  be  produced  even  in  a  mass  of  blood  effused  in  the  tissue  of  the 
lungs  ;  so  that  at  present  I  should  admit  this  formation  of  pulmonary  tubercles 
rather  as  a  mere  possibility  than  as  a  fact  proved  by  observation.  If  it  appears 
to  me  possible  for  tubercles  to  form  in  this  manner,  it  is  because  there  is  in  fact 
an  organ  where  such  appears  to  be  their  origin  ;  this  organ  is  the  spleen. 
When  tubercles  exist  here,  it  is  easy  to  prove  that  they  exist  in  the  coagulated 
blood  contained  in  the  spleenic  cellules ;  that  is  the  place  of  their  origin  and 
development.  As  to  the  rest,  I  am  now  well  convinced  that  in  much  the 
greater  number  of  phthisical  persons,  the  lungs  at  the  period  of  the  first  haemop- 
tysis, already  contained  tubercles.  Before  the  appearance  of  the  haemoptysis, 
the  existence  of  tubercles  might  be  known,  or  at  least  suspected,  either  by  per- 
cussion and  auscultation,  or  yet  more  often,  by  a  certain  number  of  rational 
signs,  which,  added  together,  have  a  much  greater  value  sometimes,  than  any 
furnished  by  our  physical  means  of  investigation.  It  is  only  in  rare  and  excep- 
tionable cases  that  haemoptysis  appears  without  some  pievious  local  or  general 
symptom  having  shown  itself  in  a  manner  to  cause  a  physician  accustomed  to 
observation,  to  suspect  the  approach  of  pulmonary  phthisis.  Some  of  these 
exceptional  cases  may  be  found  in  my  Clinique  ;  they  appear  to  me  fewer  than 
ever.  But  it  is  very  true,  that  the  existence  of  tubercles  in  the  lungs  often 
becomes  more  evident  after  the  first  spitting  of  blood.  The  disorder,  latent  at 
first  or  advancing  but  slowly,  now  unmasks  itself,  or  assumes  a  more  rapid 
course ;  and  if  too  little  observation  has  been  previously  made  upon  the  patient, 
the  beginning  of  the  pulmonary  tuberculization  is  erroneously  dated  from  the 
moment  when  the  symptoms  become  less  obscure,  and  when  the  disease  could 
escape  the  notice  of  no  one.  The  species  of  phthisis  regarded  by  some  as 
supervening  after  an  exhalation  of  blood  in  the  lungs,  that  which  Morton  has 
named  after  this  notion  phthisis  ab  hamoptoe,  is  at  least  one  of  the  most  uncom- 
mon diseases.  In  the  chapter  in  which  Morton  speaks  of  this  affection,  we  find 
that  the  greater  part  of  the  patients  described  by  him  had  already  exhibited 
before  their  haemoptysis,  symptoms  of  phthisis  ;  they  only  did  not  begin  to  fall 
into  consumption  till  after  haemoptysis  had  occurred. — Andral. 

t  It  is  to  be  observed,  that  it  is  particularly  in  individuals  whose  lungs  are 
already  tuberculous,  that  over-straining  the  voice,  great  fatigue,  violent  emotions, 
&c.  cause  or  renew  the  spitting  of  blood.  As  to  the  haemoptyses  which  follow 
a  blow  on  the  chest,  Laennec  is  very  right  in  saying  that  they  do  not  cause  pul- 
monary tubercles.  I  have  never  yet  found  a  phthisical  person  who  could  trace 
the  origin  of  his  disease  up  to  an  exterior  violence  upon  his  chest,  giving  rise  to 


OCCASIONAL    CAUSES. 


347 


morrhage  arising  without  any  obvious  cause,  but  which,  no  doubt, 
has  for  its  real  cause,  tubercles  which  had  previously,  and  per- 
haps for  a  long  time,  been  latent  in  the  lungs.* 

Among  the  occasional  causes  of  phthisis,  I  know  none  of  more 
assured  operation  than  the  depressing  passions,  particularly  if 
strong  and  of  long  continuance  ;  and  it  is  worthy  of  remark,  that 
it  is  the  same  cause  which  seems  to  contribute  most  to  the  devel- 
opment of  cancers,  and  all  the  other  accidental  productions 
which  are  not  analogous  to  any  of  the  natural  tissues.  This  is 
perhaps  the  only  cause  of  the  greater  frequency  of  consumption 
in  large  cities.  In  these,  the  single  circumstance  of  the  inhabi- 
tants having  more  numerous  relations  with  one  another,  is  in 
itself  a  cause  of  more  frequent  and  deeper  vexation  ;  while  the 
greater  prevalence  of  immorality  of  every  kind,  is  a  constant 
source  of  disappointment  and  misery,  which  no  kind  of  consola- 
tion, and  not  even  time  itself,  can  effectually  remove.  I  had 
under  my  own  eyes,  during  a  period  of  ten  years,  a  striking  ex- 
ample of  the  effect  of  the  depressing  passions  in  producing 
phthisis  ;  in  the  case  of  a  religious  association  of  women,  of  re- 
cent foundation,  and  which  never  obtained  from  the  eclesiastical 
authorities  any  other  than  a  provisional  toleration,  on  account  of 
the  extreme  severity  of  its  rules.  The  diet  of  these  persons  was 
certainly  very  austere,  yet  it  was  by  no  means  beyond  what  na- 
ture could  bear.  But  the  ascetic  spirit  which  regulated  their 
minds,  was  such  as  to  give  rise  to  consequences  no  less  serious 
than  surprising.  Not  only  was  the  attention  of  these  women 
habitually  fixed  on  the  most  terrible  truths  of  religion,  but  it 

a  spitting  of  blood.  The  following  passage  of  Morton,  so  true  in  cases  of  spon- 
taneous haemoptyses,  does  not  apply  to  these  traumatic  hsmoptyses. 

Hoc  tamen  perpetuo  fere  observare  licet,  quoties  scilicet  haemoptoe  praecedit, 
phthisin  pulmonarem  subsequi  solere  ;  ideoque  prudentem  et  honestum  medicum 
ad  curationem  haBmoptoes  evocatum  decet,  non  tantum,  praesagio  de  phthisi  sub- 
secutura  tempestive  prius  facto,  sua?  atque  etiam  artis  medicae  famae  consulere, 
vrum  etiam,  quantum  in  se  est,  cautionibus  et  medicamentis  idoneis  hunc  fatalem 
hoemoptoes  exitum  aeque  praevenire,  ac  ipsum  praesentem  morbum  curare,  saltern 
nihil  in  ejus  curatione  facere  vel  tentare,  quod  aegrum  phthisi  magis  proclivem 
reddat. — Jlndral. 

*  The  testimony  of  M.  Louis  is  most  strong  in  support  of  our  author's  opinion, 
that  haemoptysis  is  the  consequence  and  not  the  cause  of  tubercles.  He  says, 
that  during  the  last  three  years  he  had  interrogated  all  the  patients  that  came 
under  his  observation  as  to  their  having  ever  spit  blood,  and  was  always 
answered  negatively,  except  by  some  men  who  had  received  blows  on  the  chest 
and  women  who  had  labored  under  suppression  of  the  menses.  He  adds,  that 
with  these  exceptions,  this  symptom  "  indicates  in  a  manner  infinitely  probable 
the  presence  of  tubercles  in  the  lungs."  Recherches,  p.  194.  Andral  says,  that 
his  experience  leads  him  to  conclude  that  of  persons  who  have  had  hasmopty- 
sis,  one-fifth  part  have  not  tubercles  in  the  lungs,  and  that  of  those  who  die  of 
phthisis,  one-sixth  do  not  spit  blood  at  any  period  of  their  disease.  Clin.  Med. 
t.  iii.  p.  181.  Every  English  reader  is  aware  of  the  opinion  of  Dr.  Cullen,  and 
many  preceding   writers,    that   consumption    is  the   effect  of  haemoptysis,   an 

opinion    which  would  seem  to  be  still   the  prevailing  one  in  this  country. 

Trans  I. 


348  PHTHISIS    PULMONALIS. 

was  the  constant  practice  to  try  them  by  every  kind  of  contra- 
riety and  opposition,  in  order  to  bring  them,  as  soon  as  possible, 
to  an  entire  renouncement  of  their  own  proper  will.  The  con- 
sequences of  this  discipline  were  the  same  in  all :  after  being  one 
or  two  months  in  the  establishment,  the  catamenia  became  sup- 
pressed ;  and  in  the  course  of  one  or  two  months  thereafter, 
phthisis  declared  itself !  As  no  vow  was  taken  in  this  society,  I 
endeavored  to  prevail  upon  the  patients  to  leave  the  house  as 
soon  as  the  consumptive  symptoms  began  to  appear  ;  and  almost 
all  those  who  followed  my  advice  were  cured,  although  several  of 
them  exhibited  well-marked  indications  of  the  disease.  During 
the  ten  years  that  I  was  physician  of  this  association,  I  witnessed 
its  entire  renovation  two  or  three  different  times,  owing  to  the 
successive  loss  of  all  its  members,  with  the  exception  of  a  small 
number,  consisting  chiefly  of  the  superior,  the  grate-keeper,  and 
the  sisters  who  had  charge  of  the  garden,  kitchen,  and  infirmary. 
It  will  be  observed,  that  these  individuals  were  those  who  had 
the  most  constant  distractions  from  their  religious  tasks,  and  that 
they  also  went  out  pretty  often  to  the  city,  on  business  connected 
with  the  establishment.  In  like  manner,  in  other  situations,  it 
has  appeared  to  me  that  almost  all  those  who  became  phthisical, 
without  being  constitutionally  predisposed  to  the  disease,  might 
attribute  the  origin  of  their  complaint  to  grief,  either  very  deep 
or    of  long   continuance.*      Severe   continued,    or   intermittent 

*  This  is  a  most  singular  history.  It  is  to  be  regretted  that  the  author  has 
not  been  more  particular  in  his  details  as  to  the  number  of  the  sisters,  &c.  <&c. 
Such  a  statement  requires  every  confirmatory  document.  The  influence  of  the 
depressing  passions  in  giving  rise  to  diseases  of  the  lungs,  and  particularly 
phthisis,  has  been  noticed  by  many  writers.  It  is  well  known  tbat  Morton  has 
entitled  one  of  his  species  of  consumption  "  Phthisis  a  Melancholia."  In  many 
parts  of  his  "  Phtlusiologia,,,  this  author's  opinion  respecting  the  great  effect  of 
mental  causes  in  producing  this  disease,  is  strongly  expressed  : — "  Causa  vero 
horum  tuberculorum  usitissima,  est  contractio  pulmonum  leviter  spasmodica,  di- 
uturna,  et  continua,  cum  ponderis  et  oppressions  sensu,  a  mcestitia,  timore, 
curis  cogitatione  intensa,  atquc  aliis  ejusmodi  animi  pathematis  effecta.  Phthisi- 
ologia,  p.  99.  "  Ita  etiam  iste  morbus  (phthisis^)  eos,  ut  plurimum,  ex  infortunii 
alicujus  occasione  corripit  quae  res  metum,  mcestitiam,  cogitationem,  vel  aliquod 
aliud  gravius  animi  Tcdd^a  idque  diuturnum  et  fixum  prius  inducit."  lb.  p.  130. 
"Insuper,  pathemata  animi  graviora,  et  plurimum  hystericam  et  hypocondria- 
cam  affectionem,  prsecederc,  vel  saltern  comitari,  omnibus  est  notum  :  A  quibus 
scepius  quam  a  frigore,  vel  aliqua  alia  de  causa  originem  suara  ducere  solet."  lb. 
p.  242.  In  relation  to  this  subject,  the  observations  of  Avcnbrugger  respecting 
the  effect  of  nostalgia  in  producing  diseases  of  the  chest,  are  highly  worthy  of 
attention.  See  Corvisart's  Avenbrugger,  p.  170,  or  my  translation  of  the  same 
work,  p.  24. —  Transl. 

There  is  certainly  much  exaggeration  here,  and  it  is  contradictory  to  ob- 
servation to  assert  that  most  phthisical  persons  who  do  not  inherit  the  disease, 
fall  into  it  from  deep  and  long  continued  grief.  The  young  devotees  mentioned 
by  Laennec  in  support  of  his  proposition,  had  been  exposed  to  other  influences 
besides  that  of  mental  suffering.  For  my  part  I  have  not  found  that  mental 
troubles  had  a  share  in  most  cases  in  producing  pulmonary  tubercles  in  the  nu- 
merous phthisical  patients  under  my  observation  for  twenty  years,  cither  in  the 
hospitals  or  in  city  practice.    Besides,  the  age  at  which  tubercles  most  commonly 


OCCASIONAL    CAUSES. 


349 


fevers,  would  seem  to  be  pretty  often  the  occasional  cause  of  the 
production  of  tubercles  ;  since  it  is  not  unusual  to  find,  on  ex- 
amining the  bodies  of  those  who  have  died  of  these  affections,  a 
certain  number  of  tubercles,  sometimes  pretty  large,  in  the  lungs 
or  bronchial  glands,  and  more  particularly  in  the  latter.  It  is, 
however,  probable-,  that  eruptions  of  tubercles  of  this  kind  arc 
almost  always  of  small  extent,  and  rarely  succeeded  by  others, 
and  that  they  terminate  favorably  by  the  absorption  or  evacuation 
of  the  tuberculous  matter  ;  since  it  is  incomparably  more  rare  to 
find  phthisis  supervening  to  fever,  than  to  find  tubercles  in  the 
lung  of  those  who  die  of  this  disease.* 

Tubercular  consumption   has   long  passed    for   a   contagious 
disease,  and  it  is  still  looked  upon  as  such  by  the  common  people, 

begin  to  develope  themselves  in  the  lungs,  is  not  in  general  the  epoch  of  life 
when  the  mind  is  worn  by  violent  or  lasting  grief.  Melancholy  passions  appear 
to  me  to  have  a  much  stronger  influence  in  producing  organic  affections  of  the 
stomach  than  in  the  development  of  maladies  of  the  lungs.  It  is  indubitable 
that  the  origin  of  a  great  number  of  cancers  of  the  stomach  may  be  referred  to 
mental  agitations.  In  these  cases  the  disease  is  at  first  a  simple  neurosis  :  af- 
terward as  the  nervous  trouble  of  stomach  is  repeated,  the  tissue  of  the  organ 
alters,  the  nutrition  becomes  modified,  and  an  accidental  production  is  devel- 
oped. If,  besides,  the  nervous  system  has  its  share  in  the  normal  performance 
of  the  functions  of  every  organ,  which  appears  to  me  indisputable,  it  must  be 
admitted  as  a  consequence  of  this  fact,  that  there  is  not  one  of  the  organs  whose 
diseases  may  not  originate  from  a  trouble  in  this  system.  In  such  a  case  the 
function  is  first  disturbed,  then  sooner  or  later,  this  derangement  of  function 
brings  on  one  in  the  organization.  Observe  a  man  under  the  influence  of  a 
violent  emotion  :  all  the  functions  of  his  system  are  simultaneously  troubled : 
the  respiration  becomes  quick  and  gasping  :  the  action  of  the  heart  undergoes  a 
change  both  in  rapidity  and  force  :  the  digestion  is  deranged,  and  every  secre- 
tion manifests  some  alteration  either  in  quantity  or  quality.  If  these  nervous  troub- 
les are  repeated  or  prolonged,  almost  a  certain  consequence  is  that  one  of  the 
organs  affected  will  fail  in  the  proper  performance  of  its  functions,  and  in  the 
end  suffer  an  alteration  in  its  texture.  Thus  a  simple  derangement  of  the 
biliary  secretion  which  causes  almost  constantly  a  derangement  of  innervation, 
may  bring  on  a  cancerous  state  of  the  liver,  just  as  nervous  palpitations  may 
give  rise  to  hypertrophy  of  the  heart,  and  as  gastralgia  may  lead  to  a  schirrhous 
affection  of  the  stomach. — Qndral. 

*  I  have  insisted  in  my  Clinique  Medicale,  upon  these  cases  of  pulmonary 
phthisis  which  sometimes  supervene  during  the  convalescence  of  long  fevers, 
and  which  are  so  much  more  deserving  attention  as  the  phthisis,  in* such  a  cir- 
cumstance, manifests  in  many  individuals  at  least  an  aspect  altogether  peculiar 
in  its  march  and  symptoms.  But  I  cannot  agree  with  Laennec  when  he  says 
that  tubercles  very  often  form  in  the  lungs  after  these  fevers.  To  maintain  this 
assertion  Laennec  has  only  one  anatomical  proof,  namely,  the  very  frequent  ex- 
istence of  tubercles  in  the  lungs  of  persons  who  die  of  these  fevers.  I  have 
not  found  these  tubercles  so  often  as  Laennec  affirms  he  has,  and  in  cases 
where  I  have  found  them  it  has  always  seemed  to  me  much  more  natural  to 
suppose  their  existence  previous  to  the  febrile  affection.  Moreover  I  have  never 
found  thai  in  a  large  majority  of  cases,  the  persons  attacked  by  continued 
fevers,  cither  severe  or  slight,  were  more  liable  than  other  individuals  to  become 
phthisical  during  their  convalescence  from  these  disorders,  or  for  some  time 
after:  yet  these  fevers  attack  habitually  the  very  persons  who  by  their  age 
are  predisposed  to  the  development  of  tubercles  in  the  lungs.  What  I  have 
said  of  continued  fevers  applies  to  the  intermittent,  and  I  do  not  know  that  any 
exact  observation  has  yet  shown  that  they  are  really  one  of  the  occasional 
causes  of  the  development  of  tubercles  in  the  lungs. — Jlndral. 


350  PHTHISIS    PULMONALIS. 

by  magistrates,  and   by  some   medical   men,   especially   in   the 
southern  parts  of  Europe.     In  France,  at  least,  it  does  not  ap- 
pear to  be  contagious.      We   frequently   observe,   among  the 
poorer  classes,  a   numerous  family  sleeping  in  the  same  apart- 
ment with  a  consumptive  patient,  and  a  husband  occupying,  to 
the  last,  the  same  bed  with  his  wife,  without  any  communication 
of  the  disease.     The  woollen  apparel  and  the  beds  of  consump- 
tive subjects,  which  it  is  the  custom  to  burn  in  some  countries, 
are  not  generally  even  washed,  much  less  destroyed  in  France, 
and  yet  I  have  never  seen  the  disease  communicated  by  them. 
It  would  be  well,  nevertheless,  were  it  merely  on  the   score  of 
prudence  and  cleanliness,  that  greater  precautions  were  taken  in 
this  respect.      It  is  well  ascertained  that  a  disease,   not  usually 
contagious,  may  become  so  in  certain  circumstances.*     Is  it  pos- 
sible to  give  rise  to  the  matter  of  tubercle,  at  least  locally,  by 
direct   inoculation  ?     I  am  acquainted  with  only  one   fact    that 
bears  on  this  point ;  and  although  I  am  aware  that  little  stress  can 
be  laid  on  a  single  instance,  I  think  it  as  well  to  notice  it  in  this 
place.     About  twenty  years  since,  while  examining  some  verte- 
brae containing  tubercles,  I  grazed  slightly  the  fore-finger  of  the 
left  hand  by  a  stroke  of  the  saw.     The  scratch  was  so  small  that 
I  paid  no  attention  to  it ;  but  on  the  following  day  it  was  slightly 
inflamed,  and  there  gradually  formed  in  it,  and  almost  without  a 
pain,  a  small    roundish  tumor,  apparently  confined  to  the  skin, 
and  which  at  the  end  of  eight  days  was  of  the  size  of  a  large 
cherry-stone.     At  this  period,  the  epidermis  cracked  and  showed 

*  The  contagion  of  phthisis,  like  that  of  many  other  diseases,  which  are  sup- 
posed to  be  conveyed  by  an  invisible  medium,  will  in  all  probability  remain  for 
ever  a  contested  point.  The  opinion  of  the  great  majority  of  medical  men  in 
this  country  is  opposed  to  contagion  ;  and  I  think  this  opinion  is  justified  equally 
by  statistical  facts,  by  the  truths  of  pathology,  and  by  analogical  reasoning.  For 
a  strong  statistical  argument  against  the  doctrine  of  contagion,  see  Dr.  Young's 
Treatise  on  Consumption,  p.  46.  Although  myself  sceptical  as  to  the  conta- 
gious powers  of  phthisis,  from  never  having  witnessed,  among  the  thousands  of 
cases  of  this  disease  I  have  attended,  one  unequivocal  instance  of  the  fact,  it 
must  be  admitted  that  the  thing  is  in  itself  neither  impossible  nor  even  improba- 
ble. It  is  well  known  to  have  been  believed,  and  still  to  be  believed,  by  some  of 
the  most  respectable  authorities  in  physic.  Its  probability  seems  considerably 
increased  by  the  results  lately  obtained  in  France  from  the  insertion  of  pus  into 
the  veins  of  animals  :  and  a  remark  made  by  M.  Louis  in  his  treatise  on  phthisis, 
may  perhaps  be  considered  as  having  some  weight  on  the  same  side  of  the  ar- 
gument. He  informs  us  (p.  46.)  that,  in  phthisis,  the  ulcerations  of  the  trachea 
are  almost  always  situated  on  the  lack  part  of  the  tube,  while  those  of  the  epi- 
glottis are  as  constantly  on  its  lower  part; — points  which  the  sputa  rest  longest 
upon  or  touch  most  frequently,  in  their  passage  outwards.  This  would  seem 
to  prove,  at  least,  the  irritating  qualities  of  the  sputa :  but  it  is,  no  doubt,  one 
thing  to  irritate  and  inflame,  and  another  to  produce  a  specific  formation  like 
that  of  tuberculous  matter.  However,  in  a  practical  question  of  such  high  im- 
portance as  the  present,  it  is  certainly  the  duty  of  every  medical  man  to  act  cau- 
tiously, and  not  unnecessarily  to  expose  the  friends  of  his  phthisical  patients  to 
a  risk,  which,  although  he  may  deem  it  problematical  or  even  visionary,  may 
not  be  so  in  reality. —  Transl. 


OCCASIONAL    CAUSES. 


351 


us  the  small  tumor  within,  which  was  yellowish,  firm,  and  in 
every  respect  like  a  crude  yellow  tubercle.  I  cauterized  it  with 
the  deliquescent  hydro-chlorate  of  antimony,  and  felt  no  pain 
from  its  operation.  At  the  end  of  a  few  minutes,  however,  after 
the  fluid  had  penetrated  the  whole  substance  of  the  tumor,  I 
detached  it  by  a  gentle  pressure.  The  caustic  had  softened  it 
and  made  it  exactly  like  a  soft  friable  tubercle.  The  walls  of 
the  cavity  which  had  contained  this  body,  were  of  a  pearl-grey 
color,  slightly  semi-transparent,  and  without  any  redness.  I 
applied  the  caustic  afresh  to  these.  The  part  soon  healed,  and 
I  have  since  found  no  further  effects  from  the  accident.* 

If  the  question  of  contagion  is  very  doubtful,  the  case  is  very 
different  with  the  hereditary  predisposition  to  tubercles.  The 
universal  and  habitual  experience  of  practitioners  proves  that 
the  children  of  phthisical  parents  are  more  subject  to  this  dis- 
ease than  others  are.  We  happily,  however,  meet  with  numer- 
ous exceptions  to  this  rule ;  as  we  not  infrequently  see  families 
in  which  only  one  or  two  of  its  members  become  consumptive  in 
each  generation.  On  the  other  hand,  we  sometimes  find  large 
families  of  children  destroyed  by  consumption,  whose  parents 
had  never  shown  any  signs  of  the  disease.  One  family,  in  par- 
ticular, I  myself  knew,  in  which  the  father  and  mother  died  up- 
wards of  eighty  years  of  age,  and  of  acute  diseases,  after  having 
seen  fourteen  children  (born  healthy  and  without  any  seeming 
predisposition  to  the  disease)  successively  carried  off  by  consump- 
tion, between  the  ages  of  fifteen  and  thirty-five.  One  other  child 
of  the  same  family,  who  was  delicate  from  birth  and  with  decided 
marks  of  tuberculous  predisposition,  is  however  still  living,  at  the 
age  of  forty-eight,  after  having  suffered  several  severe  attacks  of 
haemoptysis,  and  appeared  to  be  more  than  once  affected  with 
phthisis.f  The  ancients,  and  especially  Aretseus,  have  carefully 
described  this  particular  temperament  or  constitution.  It  is  dis- 
tinguished by  the  brilliant  whiteness  of  the  skin,  the  bright  red 
of  the  cheeks,  the  narrowness  of  the  chest,  the  projecting  or 
winged  configuration  of  the  scapulae,  and  the  slenderness  of  the 
limbs  arid  trunk,  which  is  however  combined  with  a  certain  de- 

*  Two  French  physicians,  Hebreard  and  Lepelletier,  have  inoculated  animals 
with  the  pus  of  scrophulous  ulcers;  and  M.  Lepelletier  has  repeated  the  experi- 
ment on  himself ;  and  Kortum  and  another,  in  Germany,  have  even  ventured 
to  inoculate  children  with  the  same.  None  of  these  experiments  succeeded  so 
far  as  even  to  produce  local  effect.     {Diet,  de  Med.  t.  xix.  p.  194.) — (M.  L.) 

t  There  can  be  no  doubt  of  the  frequently  hereditary  character  of  consump- 
tion. I  mention  the  subject  here  merely  with  the  view  of  enforcing  the  vast 
importance  of  keeping  this  in  sight  in  the  physical  education  of  the  children  01 
consumptive  parents.  The  predisposition  to  tubercles  cannot  be  obviated  in 
such  cases  ;  but  no  sufficient  reason  seems  to  exist,  why  we  may  not  deviate,  by 
proper  management,  their  actual  development,  at  least  in  a  certain  portion  of 
cases. —  Transl. 


352  PHTHISIS    PULM0NAL1S. 

gree  of  adipose  and  lymphatic  stoutness.  This  particular  consti- 
tution is  attributed  by  Areta;us  rather  to  hcemoptysical  than  con- 
sumptive subjects;  and  the  remark  is  worthy  of  this  accurate 
and  clever  observer,  as  there  can  be  no  doubt  that  phthisical 
subjects  possessing  this  configuration,  are  more  subject  to  hae- 
moptysis than  others.  It  is  however  true,  that  individuals  of 
this  particular  constitution,  form  the  smaller  number  of  consump- 
tive patients ;  and  that  this  terrible  malady  frequently  cuts  oft' 
those  who  are  the  most  robust  and  have  the  best  bodily  config- 
uration.* The  ancients  thought  that  phthisis  made  its  attacks 
particularly  between  the  age  of  eighteen  and  thirty-five  ;  (Hippoc. 
Ap.  9.  sect.  v. ;)  and  it  cannot  be  denied  that  this  is  the  period 
at  which  it  is  most  commonly  manifest,  and  most  easily  recog- 
nized. Bayle,  however,  found,  in  the  hospitals  at  Paris,  that  it 
was  most  common  from  the  fortieth  to  the  fiftieth  year.  But  no 
age  is  exempt  from  it.  The  unborn  foetus  has  been  found 
affected  with  it  ;f  and  it  is  extremely  common  among  the  chil- 
dren of  the  common  people,  as  is  proved  by  the  records  of  the 
Children's  Hospital  at  Paris.  It  is  likewise  very  frequent  in  old 
age ;  I  once  opened  the  body  of  a  woman  who  died  of  this  dis- 

*  I  believe  it  is  much  less  common  to  see  robust  men  of  strong  constitutions 
become  consumptive  than  the  above  remarks  would  lead  one  to  think.  Cases 
there  are  no  doubt,  but  they  are  exceptions  ;  and  it  must  be  acknowledged  that 
in  most  instances  the  constitution  of  those  who  are  destined  to  sink  under  pul- 
monary tuberculization,  presents  a  number  of  characteristics  sufficient  to  indi- 
cate beforehand  the  development  of  this  malady,  which  almost  always  fixes  its 
roots  in  the  whole  economy,  before  manifesting  itself  by  the  local  lesion  of  the 
lungs. — Andral. 

t  The  fact  of  tubercles  being  found  in  the  foetus  is  incontestable,  but  the 
cases  are  rare:  very  few  also  are  found  in  children  before  the  second  year; 
after  this  epoch,  they  become  infinitely  more  common.  They  arc  found  even 
in  the  most  advanced  age.  Laennec  quotes  a  remarkable  example  in  this  para- 
graph, but  he  advances  an  opinion  contradicted  by  daily  observation  when  lie 
affirms  that  pulmonary  phthisis  is  vetif frequent  among  old  men.  To  lie  con 
vinced  of  the  incorrectness  of  this  assertion,  it  will  suffice  to  attend  to  patho- 
logical anatomy  a  certain  time  in  the  hospital  of  Bieetre ;  it  is  very  uncommon 
to  find  tubercles  in  the  lungs  of  the  old  men  who  die  there.  The  same  obser- 
vation may  be  made  at  the  Salpetriere.  When  it  happens  that  tubercles  are 
found  in  the  lungs  of  old  persons,  they  have  for  the  most  part.  .111  altogether 
peculiar  aspect :  they  are  hard  and  chalky  ;  the  matter  of  which  they  are  consti- 
tuted appears  saturated  with  calcareous  matter,  and  they  arc  surrounded  with  a 
black  and  indurated  tissue.  Old  men  may  also  exhibit  very  manifest  cicatrices 
of  ancient  tuberculous  excavation. 

It  has  been  calculated  that  above  a  quarter  part  of  the  individuals  who  die 
before  the  age  of  puberty,  die  with  tubercles!  but  these  accidental  productions 
must  not  be  considered  the  direct  cause  of  dcatli  in  more  than  a  sixth  of  the 
cases.  Dr.  Clark  has  estimated  that  after  the  age  of  fifteen,  the  greater  part  oi 
deaths  from  pulmonary  phthisis  take  place  between  twenty  ami  thirty,  and  thai 
the  maximum  of  mortality  in  this  disease  is  at  thirty,  and  that  from  this  point  it 
gradually  diminishes. 

The  tubercles  developed  in  infancy  affect  divers  parts,  which  are  marked  as 
follows  with  regard  to  their   comparative  frequency,  in  a  table  drawn  up  by  Dr. 


OCCASIONAL    CAUSES. 


353 


ease  upwards  of  ninety-nine  years  of  age.*     Women  are  more 
subject  to  it  than  men.f     Of  all  the  occasional  causes  which  can 

Papavoine  from  fifty  autopsis  of  children,  who  all  had  tubercles.     In  these  fifty 
cases  tubercles  were  found  in  the 


Bronchial  glands    -     -     -     -  49  times. 

Lungs 38  " 

Lymphatic  glands  of  the  neck  26  " 
Lymphatic  glands  of  the  me- 
sentery        25  " 

Spleen 20  " 

Pleura 17  " 

Small  Intestines     -     -     -     -  12  " 

Peritoneum 9  " 


Large  Intestines      ...      9  times. 

Cerebrum 5      " 

Cerebellum 3      " 

Membranes  of  the  Brain  3      " 

Pericardium none. 

Kidneys 2  times. 

Coats  of  the  Stomach  -     -       1      " 

Pancreas 1" 

Bones    -- 1      " 

Andral. 

*  The  statistical  researches  concerning  Paris,  published  under  the  authority  of 
M.  Chabrol,  tend  to  confirm  the  opinion  of  the  ancients,  as  to  the  comparative 
frequency  of  phthisis  in  early  and  advanced  life  :  the  following  are  the  decimal 
periods,  in  the  order  of  the  frequency  of  deaths  from  phthisis,  at  each  particular 
age  :  From  twenty  to  thirty,  thirty  to  forty,  ten  to  twenty,  forty  to  fifty,  fifty  to 
sixty;  birth  to  ten,  sixty  to  seventy,  seventy  to  eighty,  eighty  to  ninety,  ninety 
to  one  hundred.  It  is  proper  to  observe,  however,  that  these  tables  refer  to  tu- 
bercles in  the  lungs  only  :  had  their  occurrence  in  other  organs  been  taken  into 
account,  the  age  from  two  to  ten  would,  perhaps,  have  occupied  the  first,  instead 
of  the  sixth  place.  It  results  from  the  researches  of  M.  Lombard  at  the  Chil- 
drens'  Hospital  in  Paris,  that  of  the  children  who  die  in  their  first  and  second 
year,  tubercles  are  found  in  one-eighth  ;  in  two-sevenths  of  those  who  die  from 
two  to  three ;  in  four-sevenths  of  those  who  die  from  three  to  four  ;  and  in 
three-fourths  of  those  who  die  from  four  to  five.  In  the  succeeding  years  up  to 
puberty,  tubercles  are  more  frequent  than  before  the  fourth,  but  much  less  fre- 
quent than  from  the  fourth  to  the  fifth.  M.  Papavoine,  of  the  same  hospital, 
has  recently  published  a  statement  which  confirms  the  observations  of  M.  Lom- 
bard, although  with  some  slight  differences.  According  to  him,  the  total  num- 
ber of  tuberculous  children  between  the  fourth  and  eleventh  year,  is  greater 
than  of  those  who  are  not  tuberculous ;  tubercles  being  particularly  prevalent 
from  the  fourth  to  the  seventh  year.  Their  frequency  again  increased  about  the 
twelfth  and  thirteenth  year  ;  and  at  fourteen  and  fifteen,  the  degree  of  prevalence 
is  the  same  as  at  four  and  five.  These  results  are  obtained  from  researches  made 
on  nine  hundred  and  twenty  children  (three  hundred  and  eighty-eight  boys  and 
five  hundred  and  thirty-two  girls)  between  the  ages  of  two  and  fifteen  ;  and  out 
of  the  whole  number  no  less  than  five  hundred  and  thirty-eight  (someNvhat  less 
than  three-fifths)  were  tuberculous.  (Journ.  des  Progris,  t.  ii.  1830;  Reveu 
Med.  Juin,  1830.)— (M.  L.) 

Dr.  Young  says,  (Op.  Cit.  p.  45,)  that  "  if  we  consult  the  evidence  of  actual 
registers  of  cases,  we  shall  find  that  the  disease  is  more  frequent  above  thirty- 
five  than  below  it."  Of  two  hundred  and  twenty-three  deaths  from  phthisis 
recorded  by  Bayle  and  Louis,  twenty-one  occurred  between  the  age  of  fifteen 
and  twenty  ;  sixty-two  from  twenty  to  thirty  ;  fifty -six  from  thirty  to  forty  ;  forty- 
four  from  forty  to  fifty ;  twenty-seven  from  fifty  to  sixty  ;  thirteen  from  sixty 
to  seventy. —  Transl. 

\  This  opinion  is  corroborated  by  many  writers.  A  statement  given  by  M. 
Louis  (Op.  Cit.  p.  522,)  affords  a  strong  argument  in  its  favor:  out  of  one  hun- 
dred and  sixty-three  subjects  in  whose  lungs  tubercles  were  found  after  death, 
ninety-three  were  women  and  sixty-eight  men.  The  statistical  tables  of  Paris, 
out  of  nine  thousand  five  hundred  and  forty-two  cases  of  phthisis  give  five 
thousand  five  hundred  and  eighty-two  women,  and,  consequently,  only  three 
thousand  nine  hundred  and  sixty  men.  Several  obvious  causes  explain  the 
great  liability  of  females  to  phthisis.  "The  chief  of  these  are — their  greater 
original  delicacy  of  constitution, — their  most  deleterious  system  of  physical 
education  from  the  age  of  ten  to  puberty, — the  wearing  of  stays, — and  the  ex- 
posure of  the  upper  parts  of  the  chest. —  Transl. 
The   greater  frequency  of  pulmonary  phthisis  among  women  than   among 

43 


354 


PHTHISIS    PULMONALIS. 


give  rise  to  a  considerable  development  of  tubercles,  the  most 
powerful,  the  most  evident  and  most  frequent,  is,  unquestion- 
ably, the  softening  of  a  certain  number  of  tubercles  previously 
existing  ;  since  we  know,  as  was  formerly  remarked,  that  it  is  at 
this  period  that  the  secondary  eruptions  of  numerous  tubercles 
take  place  in  the  lungs,  and  sometimes  also  in  other  organs.*  In 
cases  of  this  kind,  at  least,  it  is  impossible  not  to  admit  the  ex- 
istence of  an  aberration  of  nutrition — an  actual  and  peculiar 
change  in  the  fluids,  which  gives  rise  to  tubercles,  and  tubercles 
only.  To  admit  with  M.  Broussais,  that  irritation  or  inflam- 
mation, which  according  to  him  are  only  degrees  of  the  same 
affection,  may  produce,  indifferently,  tubercles,  encephaloid  can- 
cer, melanosis,  fibrous,  bony,  cartilaginous  growths,  &c,  is  to 
avow  at  once  that  inflammation  itself  is  only  an  occasional  cause. 
We  must  look  for  some  other  cause  to  account  for  the  production 
of  tubercles  rather  than  the  encephaloid  cancer, — or  for  an  erup- 
tion of  tubercles  affecting  nearly  all  the  organs  of  the  body, 
rather  than  the  development  of  a  cartilaginous  substance  confined 
to  the  part  first  affected,  and  converting  the  tuberculous  ulcer 
into  a  fistula  with  hardly  any  evil  consequences  to  the  general 
health.f 


men  is  generally  admitted  by  the  French  Physicians,  and  their  opinion  is  founded 
on  statistical  accounts  taken  at  Paris  on  this  subject.  Similar  accounts  however, 
taken  in  other  places,  do  not  lead  to  the  same  result,  but  on  the  contrary  show 
the  disease  to  be  more  common  in  men.  Dr.  Clarke  has  given  the  following 
table. 


Country  where  the 

Men  died 

Women  died 

Proportion  of 

observations  were  made. 

of  phthisis. 

of  phthisis. 

men  to  women. 

Hamburg 

555 

445 

10  to     8.7 

Hospital  of  Rouen 

55 

44 

10   "     8.6 

Hospital  of  Naples 

382 

315 

10  "     8.2 

New  York 

1584 

*     1370 

10   "     8.6 

Geneva 

71 

62 

10   "     8.7 

Berlin 

328 

292 

10  "     8.8 

Sweden 

2088 

1860 

10  "     8.9- 

Sweden 

3054 

3103 

10  "  10.4 

Berlin 

560 

655 

10   "   11.6 

New  Yoik  (among  the  blacks) 

47 

58 

10  "  12.3 

Paris 

2219 

2970 

10   "   13.3 

Paris 

3965 

5579 

10  "  14.3 

Berlin  (children  of  both  sexes) 

363 

567 

10   »  15.6 

This  last  item  is  remarkable  in  showing  that  while  at  Berlin  the  number  of 
masculine  consumptive  adults  is  greater  than  that  of  the  feminine,  the  inverse 
of  this  is  the  fact  in  infants.  It  is  very  desirable  that  similar  researches  should 
be  pursued  and  extended.— Andral. 

In  making  this  statement,  I  think  our  author  is  justly  chargeable  with  the 
application  of  the  axiom  so  much  reprobated  by  himself— post  hoc,  ergo  propter 
hoc.  Why  should  not  the  original  causes  of  the  first  crop  of  tubercles  be  still 
in  operation  ? — Transl. 

t  Among  many  other  occasional  causes  usually  enumerated  by  authors,  and  un- 
noticed by  M.  Laennec,  the  inhalation  ofdnst,  by  various  classes  of  artizans  and 


PHYSICAL    SIGNS.  355 

Sect.  V. — Physical  signs  of  tubercles. 

With  the  exception  of  some  very  rare  cases,  tubercles    first 
make  their  appearance  in  the  summit  of  the  lungs.     It  is  in  this 

others,  dserves  notice;  although  I  am  of  opinion  that  bronchitis  and  not  phthisis 
is  the  disease  commonly  produced  by  causes  of  this  kind.  The  same  remark  is 
applicable,  I  conceive,  to  the  great  majority  of  the  cases  of  consumption  compli- 
cated with  gastric  disorder,  and  termed  dyspeptic  phthisis  by  Dr.  Philip. — Transl. 
In  this  chapter  which  is  devoted  to  an  examination  of  the  causes  which 
favor  the  development  of  pulmonary  phthisis,  Laennec  has  not  touched  upon 
the  question  of  the  influence  exercised  in  causing  this  malady  by  the  divers 
occupations  of  men.  He  has,  for  example,  said  nothing  of  the  effect  which 
breathing  an  air  charged  with  molecules  may  have  in  producing  pulmonary 
tubercles  by  irritating  the  bronchi.  Are  the  individuals  who  breathe  such 
an  air  more  likely  to  become  phthisical  ?  Many  physicians  do  not  hesi- 
tate to  say  yes  !  but  recent  researches  throw  at  least  a  doubt  upon  the  point. 
Thus  Parent  du  Chatelet  has  shown  that  the  workmen  in  snuff  manufactories 
are  not  more  phthisical  than  others.  The  same  author  has  also  made  re- 
searches respecting  the  pectoral  condition  of  a  great  number  of  workmen 
laboring  habitually  in  the  midst  of  a  dust  so  thick  that  they  can  hardly  be 
seen ;  he  has  shown  that  individuals  of  a  good  constitution  do  not  become 
diseased  in  such  an  atmosphere ;  but  he  has  observed  that  persons  already 
phthisical,  or  with  a  tendency  to  become  so,  are  not  proof  against  it.  (Annates 
d' Hygiene  publiquc,  torn,  x.)  •  Still  there  are  some  of  these  workmen  among 
whom  pulmonary  phthisis  is  certainly  more  common,  such  as  the  flint  hammer- 
ers of  Meunes,  mentioned  in  the  former  part  of  this  work.  But  here  for  the 
most  part,  many  causes  unite,  sometimes  cold,  sometimes  the  want  of  air  and 
light,  sometimes  excessive  fatigue,  or,  on  the  other  hand,  a  life  too  sedentary, 
and  in  many  cases,  unhappincss  and  all  its  'consequences.  Each  one  of  these 
influences  must  be  allowed  its  part :  and  this  makes  sucli  inquiries  very  delicate. 
We  will  refer,  however,  to  some  positive  results.  The  greater  part  of  the  fol- 
lowing will  be  found  in  Dr.  Clark's  work  on  consumption;  the  extracts  are 
nearly  literal.  According  to  Dr.  Alison  of  Edinburgh,  most  of  the  stone-cutters 
of  that  city  in  constant  occupation,  hardly  ever  reach  the  age  of  fifty  years 
without  showing  signs  of  pulmonary  phthisis. 

Dr.  Thackrah  states  that  the  workmen  generally  die  with  pectoral  symptoms 
before  forty.  Dr.  Forbes  states  that  in  Cornwall  a  great  many  miners  are  car- 
ried off  by  chronic  pectoral  inflammations.  The  same  observations  have  been 
made  in  many  parts  of  England  upon  workmen  engaged  in  filing  copper,  and 
nothing  is  more  remarkable  in  this  relation  than  the  account  given  by  Dr. 
Knight  of  the  Sheffield  cutlers.  These  are  about  2500  in  number.  Out  of 
these,  150,  viz.  80  adults  and  70  children,  are  employed  in  polishing  forks. 
They  work  at  dry  polishing,  and  die  between  28  and  32  years.  The  razor 
polishers  work  either  at  dry  or  wet  polishing,  and  they  die  from  40  to  45  years. 
The  knife-grinders  work  upon  wet  stones,  and  their  lives  are  prolonged  to  50 
years.  In  comparing  the  diseases  of  these  laborers  with  those  of  the  workmen 
employed  in  the  other  workshops  of  Sheffield,  Dr.  Knight  has  found  that  out  of 
250  patients  among  the  polishers,  150  had  pectoral  complaints;  while  out  of 
the  same  number  of  other  workmen,  only  56  had  any  affection  of  the  respira- 
tory apparatus.  In  examining  the  respective  ages  of  the  polishers  and  other 
artizans  of  Sheffield,  we  find  the  following  very  remarkable  results. 

Age.  Polishers.  Other  Artisans. 

70  years.  124  140 

75  83  118 

40  40  92 

45  24  70 

50  10  56 

55       .  4  34 

60  1  19 

286  529 


356 


PHTHISIS    PULMONALIS. 


place,  therefore,  that  we  must  seek  them.     The   earliest  signs 
usually  show  themselves  below  the   clavicle.     Small   tubercles, 


The  disease  which  carries  off  the  polisher  by  the  time  half  the  career  of 
human  life  is  accomplished,  is  known  at  Sheffield  by  the  name  of  the  Polisher's 
Asthma. 

It  has  also  been  remarked  that  the  polishers  who  work  in  Sheffield  die  sooner 
than  those  who  work  in  the  country. 

M.  Benoiston  de  Chateauneuf  has  studied  with  the  help  of  statistics  the  influ- 
ence of  certain  professions  on  the  development  of  pulmonary  phthisis  :  he  gives 
the  following  table  of  deaths  of  this  disease  at  the  Hotel  Dieu,  La  Charite,  La 
Pitie,  and  the  Hospital  Cochin  from  1817  to  1827.  (Annates  a"  Hygiene  Pub- 
lique.) 

1.  Professions  exposing  the  lungs  to  the  action  of  an  atmosphere  loaded  with 
vegetable  particles. 

MEN. 


Entered.  Died. 

Starch  Manufacturers  98  1 

Bakers  2702  56 

Colliers  (Char.oal)  375  14 

Porters  246  6 

Rag  Pickers  590  5 

Cotton  Spinners  319  6 

Spinners  594  14 


Proportion  mitof  100. 
1.02 
2.07 
3.73 
2.43 
0.84 
1.88 
2.35 


4924 

102 

Mean 

proportion 

2.07 

WOMEN. 

Rag  Pickers 

237 

4 

1.68 

Cotton  Spinners 

882 

24 

2.72 

Yarn  Winders 

263 

9 

3.42 

Spinners 

1173 

19 

1.61 

2555 


56 
Mean  proportion  2.19 


2.  Professions  exposing  the  lungs  to  the  action  of  an  atmosphere  loaded  with 
mineral  particles. 


Entered. 

Died. 

Proportion  out  of  100. 

Stone  Cutters  (in  quarry)  887 

13 

1.46 

Masons 

4071 

90 

2.22 

Marble  Cutters 

162 

2 

1.25 

Workers  in  Plaster 
Stone  Hammerers 

158 

4 

2.53 

551 

5 
114 

0.90 

5829 

Mean 

proportion 

1.95 

3.  Professions  exposing  the  lungs  to  the  action  of  an  atmosphere  loaded  with 
animal  molecules. 

MEN. 
Died. 
10 
4 

47 
3 


Entered 
Brush  Makers  283 

Carders  and  quilt  makers  129 
Hatters  983 

Workers  in  Feathers  39 


Proportion  out  of  100. 
3.53 
3.10 

4.78 
7.69 


1434  64 

Mean  proportion  4.46 


PHYSICAL    SIGNS. 


357 


separated  from  one  another  by  portions  of  healthy  lung  cannot 
be  recognized.     But  at  this  period  of  their  progress,  the  health 


Brush  Makers  103 

Carders  and  quilt  makers  4."»1 
Hatters  130 

Workers  in  Feathers  61 


745 


WOMEN. 

8 
11 
01 
07 

27 


7.76 

2.43 

0.55 

11.47 


Mean  proportion  3.39 


4.  Professions  exposing  the  lungs  to  the  action  of  an  atmosphere  loaded  with 


noxious  vap 

Gilders 

Ornamental 

Smokers 

ors. 
painters 

Entered. 

545 
2160 

389 

MEN. 

Died. 

29 

47 

13 

89 
Mean 

Proportion  out 
5.32 
2.17 
3.34 

>»/ 

100. 

3094 

proportion  2.87 

Gilders 

285 

WOMEN. 
16 

5.61 

Mean  proportion  5.61 

5.  Professions  exposing  the  body,  and  especially  the  lower  extremities,  to  the 
action  of  humidity. 

Entered.  Died.  Proportion  out  of  100. 

Washermen  218  4  1.83 

Washerwomen  2775  125  4.50 

6.  Professions  exposing  the  muscles  of  the  chest  and  the  upper  extremities  to 
a  painful  and  continual  exercise. 

MEN. 


Entered. 

Died. 

Proportion  out  of  100. 

Weavers 

'  935 

20 

2.13 

Gasmen 

251 

8 

3.18 

Carpenters 

268 

4 

1.49 

Joiners 

1716 

53 

3.08 

Blacksmiths 

214 

2 

0.93 

Locksmiths 

668 

5 

0.74 

Water  Carriers 

373 

9 

2.41 

Stone  Sawyers 

702 

8 
109 

1.13 

5127 

Mean 

proportion  2.12 

WOMEN. 

Weavers 

163 

3 

1.84 

Gas-women 

253 

8 

3.16 

416  11 

Mean  proportion  2.64 
7.  Professions  exposing  the  muscles  of  the  chest  and  the  arms  to  a  perpetual 
movement,  and  the  body  to  a  constant  bending. 

MEN. 

Died.  Proportion  out  of  100. 

43  4.73 

46  6.43 


Writers 
Jewellers 


Entered. 
908 
715 


358  PHTHISIS    PULMONALIS. 

is  commonly  still  good,  and  the  cough  too  slight  to  induce  the 
patient  to  consult  a  medical  man.* 

Signs  of  the  accumulation  of  crude  or  miliary  tubercles. — 
When  miliary  tubercles  are  accumulated  in  great  numbers  in  the 
upper  portions  of  the  lungs,  the  sound  resulting  from  percussion 
of  the  clavicles  becomes  less,  and  is  usually  unequal.  The  right 
lung  being  in  general  the  earliest  and  most  severely  affected,  the 
defect  of  resonance  is  almost  always  on  the  right  side.  This 
deficiency  of  sound  extends  sometimes  over  the  upper  and  fore 
parts  of  the  chest  as  low  as  the  fourth  rib.f  These,  indeed,  are 
the  only  parts  of  the  chest  where  the  mere  accumulation  of  tuber- 
cles can  give  rise  to  this  phenomenon  ;J  if  we  except  the  inter- 


Tailors 

1048 

49                          4.67 

Shoe  makers 

1818 

78                          4.29 

Fringe  makers 

436 

20                          4.69 

Crystal  Cutters 

244 

15                          614 

Polishers 

270 

12                          4.44 

5429 

263 
Mean  proportion  4.84 
WOMEN. 

Jewellers  , 

39 

4                        13.33 

Tailors 

1069 

49                          4.58 

Shoe  makers 

397 

22                          5.54 

Fringe  makers 

534 

25                          4.68 

Polishers 

548 

21                          3.83 

Embroiderers 

593 

51                          8.60 

Dress  makers  &  Millin.  5392  296  5.48 

Flower  makers                   357  31  9 

Lace  makers                       258  16  6.20 

Patchers  &  Menders         540  33  6.11 


10.129  574 

•        Mean  proportion  5.66 

In  a  subsequent  table  of  deaths  by  phthisis  in  these  seven  classes  of  profes- 
sions, M.  Benoiston  de  Chateauneuf  has  found  the  mean  number  of  deaths  to 
be  in  men  2.85  in  100,  and  in  women  4.75  a  result  which  confirms  what  we  have 
said  in  a  preceding  note,  that  the  mortality  by  consumption  is  greater  at  least 
at  Paris  among  women  than  among  men. 

However  interesting  this  view  maybe  in  some  points,  it  seems  to  me  to  throw 
no  great  light  on  the  principal  question.  In  fact,  it  is  clear  that  in  most  of  the 
occupations  mentioned,  many  influences  combine  to  produce  the  tuberculization 
of  the  lungs.  Besides,  M.  Benoiston  should  have  drawn  up  another  table  as  a 
counterpart  to  the  above,  showing  the  proportion  of  phthisical  persons  among 
the  individuals  not  engaged  in  the  occupations  above  described. — Andrei. 

*  Doubtless  perfect  health  may  be  preserved  if  the  tubercles  thus  separated 
by  a  sound  parenchyma,  are  few;  but  if  they  are  numerous,  they  cause  acci- 
dents ;  they  may  even  determine  the  gravest  symptoms  and  bring  on  death 
without  auscultation  and  percussion  being  able  to  discover  their  existence. — 
Jindral. 

t  In  no  case  is  the  importance  of  percussion  so  frequently  and  strikingly  evin- 
ced as  in  the  earlier  stages  of  phthisis.  A  single  blow  on  the  clavicle  will  often 
afford  the  means  of  a  more  certain  diagnosis  and  prognosis,  than  weeks  or  even 
months  of  observation  of  the  general  symptoms.  How  often  have  I  heard  in  this 
ominous  sound  the  death-knell  of  my  patients.—  Transl. 

t  I  cannot  here  agree  with  Laennec    The  accumulation  of  tubercles  in  the 


PHYSICAL    SIGNS. 


359 


scapular  region,  in  which  we  sometimes  find  a  deficiency  of  sound, 
owing  to  the  great  accumulation  of  tubercles  at  the  roots  of  the 
lungs  and  in  the  bronchial  glands.  When  the  sign  just  men- 
tioned exists,  and  even  where  it  is  wanting,  a  diffused  broncho- 
phony, more  or  less  marked,  is  perceived  beneath  the  clavicle, 
over  the  infraspinal  fossa  of  the  scapula,  and  in  the  axilla.  We 
must,  however,  disregard  this  last  sign,  if  it  is  perceived  only 
about  the  inner  and  upper  angle  of  the  scapula,  on  account  of 
the  vicinity  of  the  bronchi.* 

Signs  of  the  softening  of  tubercles. — When  the  tubercles  begin 
to  soften,  the  same  signs  continue ;  and  in  addition  to  these,  the 
cough  gives  rise  to  a  kind  of  guggling,  as  if  the  matter  that  pro- 
duced it  were  thick,  and  agitated  en  masse.  The  guggling, 
however,  soon  becomes  more  liquid  and  more  like  the  mucous 
rhonchus ;  and  the  cough,  transformed  to  cavernous,  indicates 
the  formation  of  a  pulmonary  excavation.     In  proportion  as  this 

superior  lobe  of  either  lung  may  be  discovered  behind  as  easily  as  before,  by  a 
diminution  in  the  normal  sound  of  the  chest.  However  feeble  may  be  the 
natural  resonance  of  the  chest  in  the  super  spinal  fossae,  I  have  yet  known 
many  oases  where  the  sounds  arising  from  these  parts  differed  from  one  another, 
and  in  the  part  of  the  lung  corresponding  to  the  duller  sound  there  were  tuber- 
cles. Often,  too,  when  the  whole  upper  lobe  of  one  of  the  lungs  is  filled  by 
tubercles,  a  remarkably  flat  sound  is  found  in  the  corresponding  sub-spinal  fos- 
sae ;  moreover,  a  remarkable  difference  of  sound  may  be  discovered  in  the  axilla. 

Tubercles,  numerous  but  small,  often  exist  without  any  way  modifying  the 
resonance  of  the  chest.  There  are  also  cases  where  similar  tubercles  are  de- 
veloped in  the  substance  of  a  lung  already  inflamed,  or  which  afterwards  be- 
comes so  :  in  such  cases  the  tuberculated  portion  of  the  lung  not  only  sounds 
less  clear,  but  the  corresponding  walls  of  the  chest  exhibit  a  sound  altogether 
peculiar. — Qndral. 

*  To  this  symptom  furnished  by  auscultation  of  the  voice  must  be  added  those 
given  by  auscultation  of  the  respiratory  sound  :  here  the  following  cases  may 
occur — 

1st.  The  respiratory  sound  preserves  all  its  purity,  softness  and  strength. 
This  is  the  case  when  the  tubercles,  although  very  numerous,  are  small,  and 
separated  by  wide  intervals  in  which  the  tissue  of  the  lung  has  preserved  all  its 
permeability. 

2nd.  The  respiratory  sound  becomes  much  more  feeble  in  the  regions  where 
tubercles  exist;  the  resonance  of  the  chest  is  more  obscure  or  not  at  all  modified, 
which  is  far  from  being  uncommon,  or  becomes  clearer  which  can  only  happen 
when  there  is  an  accompanying*emphysema. 

3d.  The  respiratory  sound  becomes  double ;  one  corresponds  to  the  moment 
when  the  air  penetrates  the  bronchi :  this  is  the  only  sound  which  is  heard  in  a 
normal  state ;  it  may  be  very  strong,  but  without  its  customary  softness :  it  may 
also  become  very  feeble,  with  for  example  two  or  three  times  less  intensity  than 
the  sound  which  accompanied  inspiration  on  the  other  side.  A  second  sound 
follows  this,  sometimes  faint  and  perceptible  only  when  the  patient  is  directed 
to  breath  deep  ;  sometimes  very  strong,  resembling  a  sort  of  blowing,  and  almost 
entirely  obscuring  the  preceding  sound.  This  second  sound  takes  place  during 
expiration.  I  have  spoken  of  it  in  the  preceding  notes  and  refer  to  it  again  be- 
cause  1  think  it  a  very  important  sign,  by  the  help  of  which  I  have  often  been 
able  to  discover  in  what  point  of  the  lungs  the  tubercles  were  agglomerated  and 
where  the  cavities  existed.  This  expiratory  sound  indicates  the  existence  of 
tubercles  already  large,  and  which  have  obliterated  some  of  the  bronchial  tubes. 

Ji  may  be  heard  cither  in  the  sub-clavicular  regions,  or  in  the  sub  and  super 
spinal  fussa.'. — .iudrnl. 


360  PHTHISIS    PULMONALIS. 

empties  itself,  the  rospiration  also  assumes  the  cavernous  char- 
acter, and,  together  with  the  cough,  points  out  the  increasing 
extent  of  the  cavity.  The  diffused  bronchophony  then  gives  way 
to  pectoriloquy,  which  is  at  first  imperfect,  and  frequently  inter- 
rupted, but  gradually  becomes  more  distinct.  Sometimes,  in 
proportion  as  the  excavation  empties  itself,  the  resonance  of  the 
chest,  which  had  been  obscure,  becomes  clearer ;  and  I  have 
known  physicians  deceived  by  this  circumstance,  so  as  to  imagine 
that  their  patient  was  improving.  Most  frequently,  however, 
even  after  the  formation  of  a  considerable  excavation,  the  sound 
does  not  become  louder,  because  there  is  developed  at  the  same 
time  around  it,  a  great  number  of  crude  tubercles.*  It  is  also  at 
this  time  when  the  tuberculous  matter  begins  to  soften,  that  we 
sometimes  perceive  on  percussion,  a  guggling,  or  a  jar,  like  that 
yielded  by  a  cracked  pot,  and  accompanied  by  the  resonance  in- 
dicative of  the  presence  of  a  cavity.  This  sign  always  points 
out  that  the  excavation  is  very  near  the  surface  of  the  lung ;  and 
is  never  observed  except  in  lean  subjects,  the  walls  of  whose 
chest  are  thin,  and  the  ribs  more  than  usually  movable.  When 
a  superficial  excavation  has  some  of  its  walls  thin,  soft,  and  not  ad- 
hering to  the  costal  pleura,  the  phenomenon  which  I  have  termed 
the  auricular  puff,  simple,  or  veiled,  frequently  accompanies  the 
cavernous  respiration  and  cough,  as  well  as  the  pectoriloquy.  In 
this  case,  every  word  is  followed  by  a  puff  like  that  used  in 
blowing  out  a  candle,  and  which  would  be  mistaken  for  a  puff 
in  reality,  if  the  sense  of  touch  did  not  rectify  that  of  hearing. 
By  making  the  patient  speak  in  monosyllables,  we  ascertain  that 

*  As  the  tubercles  soften  and  form  cavities,  the  sound  not  only  docs  not  be- 
come louder,  but  in  the  greater  number  of  cases  it  becomes  more  obscure  and 
grows  altogether  flat.  The  cause  is  this  :  around  the  first  tubercles,  others  are 
formed  which  gradually  invade  the  whole  parenchyma  and  render  it  less  and 
less  permeable  to  the  air.  The  tissue  of  the  lungs  may  also  harden  around 
them,  being  in  an  inflammatory  state,  which  develops  and  maintains  the  acci- 
dental production. 

As  long  as  there  is  no  softening  of  the  tubercles,  the  respiratory  sound  is  only 
modified  in  intensity;  its  purity  is  not  affected  Ivy  the  existence  of  rhonchi.  At 
this  stage  of  the  disease,  auscultation  discovers  nothing  which  indicates  a  mor- 
bid state  of  the  mucous  membrane  of  the  bronchi,  one  proof  out  of  many  that 
this  membrane  suffers  only  a  sympathetic  irritation  while  the  tubercles  are  in  a 
state  of  crudity,  and  that  it  is  not  the  inflammation  which,  in  extending  to  the 
air  vesicles  or  the  tissue  of  the  lung,  gives  rise  to  the  tubercles.  If  this  were 
the  fact,  it  appears  to  me  that  in  the  earlier  stage  of  every  pulmonary  phthisis 
we  ought  to  hear  a  rhonchus,  either  mucous,  subcrepitous,  sibilous  or  sonorous, 
as  they  are  heard  whenever  the  smaller  bronchi  are  the  seat  of  an  inflammation 
ever  so  short  or  slight.  Moreover,  when  I  hear  no  rhonchus  any  where  in  an 
individual  with  a  cough  of  long  standing,  I  have  a  stronger  suspicion  of  tuber- 
cles than  if  I  had  discovered  either  one  of  the  numerous  varieties  of  the  humid 
rhonchi,  or  one  of  the  dry  rhonchi  which  are  so  often  connected  with  the  exis- 
tence of  an  inflammatory  engorgement  cither  acute  or  chronic,  of  the  mucous 
membrane  of  the  bronchi. — Andral. 


physical  signs.  361 

the    puff    immediately  succeeds,  rather    than  accompanies,    the 
voice. 

Signs  of  the  complete  discharge  of  the  tuberculous  matter. — 
When  a  tuberculous  excavation  is  completely  empty,  this  state 
is  clearly  indicated  by  the  cavernous  respiration  and  cough.  In 
most  cases  the  cavernous  rhonchus  is  no  longer  heard ;  and  if  it 
sometimes  takes  place,  owing  to  a  secretion  going  on  from  the 
walls  of  the  cavity,  it  is  only  temporarily,  and  frequently  disap- 
pears for  several  hours,  after  the  patient  has  expectorated.  At 
this  period,  and  often  long  before  this,  pectoriloquy  becomes 
quite  perfect.  I  have  in  a  former  part  of  this  volume  described 
pectoriloquy,  the  most  important  of  those  signs  which  point  out 
a  pulmonary  excavation.  On  account  of  its  great  value,  how- 
ever, I  think  it  proper  to  enlarge  a  little  more  on  it,  in  this  place. 
I  formerly  stated  that  pectoriloquy  may  be  perfect,  imperfect,  or 
doubtful,  that  it  may  be  suspended  for  some  time,  and  in  certain 
cases  even  disappear  almost  entirely.  When  pectoriloquy  is 
doubtful,  and  exists  only  in  the  interscapular  region,  below  the 
axilla,  or  towards  the  junction  of  the  clavicle  and  sternum,  we 
must  lay  no  stress  on  it.  Indeed,  we  may  extend  the  same  re- 
striction to  the  whole  of  the  upper  parts  of  the  chest  as  low  as 
the  upper  rib,  when  the  phenomenon  is  very  doubtful,  and  as 
perceptible  on  one  side  as  the  other.  This  restriction  is  founded 
on  the  circumstance  of  there  being  more  bronchial  tubes  of  a  cer- 
tain diameter  in  the  top  of  the  lungs  than  elsewhere.  These  are 
sometimes  very  superficial ;  and  when  this  is  the  case  they  fre- 
quently give  rise  to  the  phenomenon  in  question  ;  which  is,  in  point 
of  fact,  only  bronchophony.  When  we  explore  the  space  between 
the  clavicle  and  upper  edge  of  the  trapezius  muscle,  we  must  be 
very  careful  to  keep  the  stethoscope  perpendicular  ;  because  if 
we  give  it  the  slightest  direction  towards  the  neck,  we  hear  the 
natural  resonance  of  the  voice  in  the  larynx  and  trachea,  and 
will  be  very  apt  to  confound  this  with  pectoriloquy,  if  not  much 
accustomed  to  the  practice  of  auscultation.  But  when  this 
doubtful  pectoriloquy  is  observed  below  the  third  or  fourth  rib, 
or  on  one  side  only,  it  affords  at  least  a  strong  presumption  of 
the  existence  of  an  excavation  ;  and  if,  at  the  same  time,  it  does 
not  exist  in  the  points  above  mentioned,  the  presumption  may  be 
considered  as  amounting  to  certainty :  we  have  only  to  think 
that  the  cavity  is  situated  deep  within  the  pulmonary  substance, 
or  tha^t  it  is  still,  in  a  great  measure,  filled  with  tuberculous 
matter  imperfectly  softened.  In  whatever  parj  of  the  chest  it 
may  be,  when  the  resonance  of  the  voice  is  much  stronger  than 
on  the  opposite  side,  and  particularly  if  it  is  so  intense  as  to 
seem  louder  and  nearer  the  car  of  the  observer,  than  the  natural 
voice  heard  without  the  stethoscope,  we  may  consider  the  sign 
46 


362  PHTHISIS    PULMONALIS. 

quite  as  certain  as  if  the  voice  traversed  the  tube  oi  the  instru- 
ment ;  and  in  such  case  we  say  the  pectoriloquy  is  imperfect  and 
not  doubtful.  Between  the  most  perfect  pectoriloquy  and  that 
which  is  completely  doubtful,  there  are  many  degrees  which  can 
only  be  learned  by  habit,  and  which  it  would  be  as  difficult  as  it 
would  be  superfluous  to  describe.  In  one  degree,  for  example, 
the  voice  seems  to  enter  a  short  way  into  the  extremity  of  the 
tube,  but  does  not  traverse  it  completely.  Pectoriloquy  is  more 
distinct  according  as  the  voice  of  the  individual  is  more  shar.p  ; 
and  as  women  and  children  are  the  subjects  in  which  this  char- 
acter is  most  strikingly  marked,  we  must  be  particularly  on  our 
guard,  in  them,  not  to  confound  with  pectoriloquy  the  doubtful 
bronchophony  which  exists  naturally  in  some  points  of  the  chest. 
In  men,  on  the  other  hand,  who  have  a  very  deep  voice,  pecto- 
riloquy is  frequently  imperfect,  and  sometimes  doubtful,  even 
when  there  exist  in  the  lungs  excavations  of  the  sort  best  calcu- 
lated for  producing  it.  The  deeper  the  voice  is,  the  resonance 
within  the  chest  is  found  to  be  the  stronger ;  and  in  cases  of  this 
kind,  the  natural  vibration  of  the  walls  of  the  thorax  is  sometimes 
so  great  as  to  mask  the  pectoriloquy.  In  such  persons,  the  voice, 
tremulous  and  agitated,  seems  unable  to  penetrate  the  tube,  but 
resounds  at  its  extremity  twice  or  thrice  as  loud  as  when  heard 
by  the  naked  ear.  The  patient  seems  as  if  he  spoke  through  a 
speaking  trumpet,  quite  close  to  us,  and  not  through  a  tube  into 
our  ear.  This  particular  phenomenon  is  as  characteristic  of  the 
lesion  in  question  as  pectoriloquy,  and  quite  sufficient  for  prac- 
tical conclusions,  especially  if  it  exists  on  one  side  only.  It  be- 
comes more  striking,  as  formerly  observed,  if  we  shut  the  other 
ear  :  and,  indeed,  the  difference  of  the  resonance  of  the  voice  in 
the  diseased  and  sound  portions  of  the  lungs,  is  then  so  great  as 
to  render  the  certainty  of  an  excavation  quite  as  complete  as  if  it 
were  announced  by  the  most  perfect  pectoriloquy.  It  is  only 
when  slight  and  equally  distinct  on  both  sides  of  the  chest,  that 
we  can  entertain  any  doubts  of  its  import.  The  most  evident 
pectoriloquy  may  present  very  striking  differences  :  in  some,  the 
voice  passes  uninterruptedly  through  the  cylinder ;  in  others,  it 
is  intermittent,  and  heard  only  by  fits,  some  of  the  sharper  tones 
merely  reaching  the  ear  occasionally.  This  intermission  occurs 
when  the  excavations  open  into  bronchi  of  a  small  size,  or  when 
the  openings  continue  to  be  partially  obstructed  by  the  sputa : 
whether  interrupted  or  continuous,  however,  the  phenomenon  is 
equally  characteristic.  Even  in  cases  of  perfect  and  continuous 
pectoriloquy,  the  sound  is  sometimes  interrupted  by  a  similar 
cause  ;  as  we  frequently  find  it  wanting  in  patients  who  had  ex- 
hibited it  in  the  most  striking  manner  only  a  few  hours,  or  even 
mintttes  previously.      In  cases  of  this  kind,  the  existence  of  the 


PHYSICAL    SIGNS.  363 

cavernous  rhonchus  in  the  point  where  pectoriloquy  had  been 
observed,  leaves  no  doubt  as  to  the  cause  of  the  cessation  of  the 
latter.  For  this  reason,  we  must  never  pronounce  a  phthisical 
patient  to  be  non-peetoriloquous,  until  after  we  have  examined 
him  several  times,  at  different  hours  of  the  day,  and  particularly 
just  after  he  has  been  expectorating.  It  frequently  happens  in 
these  cases  of  suspension,  that  coughing  will  restore  the  pecto- 
riloquy instantly.  This  phenomenon  presents  still  other  varie- 
ties in  relation  to  the  character  of  the  voice  itself :  the  articulation 
of  the  words  may  be  more  or  less  distinct ;  the  sound  of  the 
voice  may  be  more  or  less  changed.  In  most  cases  the  voice  is 
a  little  sharper  than  when  heard  in  the  natural  manner,  and  is 
moreover  somewhat  smothered,  like  that  of  ventriloquists.  As 
with  these  mimics  also,  the  articulation  of  certain  words  is  very 
distinct,  while  that  of  others  is  very  obscure.  Sometimes  the 
voice  is  feebler  than  the  natural  voice  of  the  patient ;  but  usually 
it  is  stronger.  I  have  frequently  observed,  while  examining  pa- 
tients in  whom  pectoriloquy  existed  in  the  back,  and  whose  voice 
was  very  weak,  that  I  could  frequently  hear  their  replies,  through 
the  cylinder ;  whilst,  at  the  same  distance,  I  could  only  hear, 
without  it,  some  broken  words.  Finally,  in  cases  of  individuals 
with  a  deep  voice,  but  in  whom  pectoriloquy  is  perfect,  the  voice 
seems  conveyed  to  the  ear  by  a  speaking  trumpet  rather  than  a 
tube.  Sometimes  the  patient  appears  speaking  right  into  the 
ear,  without  any  conveyance,  and  so  loudly  as  to  be  disagreeable. 
The  most  complete  extinction  of  the  voice  does  not  prevent  pec- 
toriloquy from  being  heard  :  I  have  found  it  very  evident  in  in- 
dividuals whose  voice  was  so  low  as  to  be  inaudible  three  or  four 
feet  distant.*  Pectoriloquy,  as  I  have  already  observed,  is  the 
more  evident,  the  thinner  the  walls  of  the  excavation  are ;  but 
the  difference  of  a  few  lines  in  this  respect,  is  of  no  great  conse- 
quence. I  have  found  it  very  distinct  where  the  excavatiqn  was 
situate  more  than  an  inch  beneath  the  surface,  and  surrounded 
by  a  portion  of  lung  very  healthy  and  quite  permeable  to  the 
air ; — a  condition  of  parts  which  would  seem  very  little  favor- 
eble  to  the  propagation  of  sound.  The  excavations,  which  are  of 
a  middling  size,  and  with  few  anfractuosities,  afford  the  most  per- 
fect pectoriloquy  ;  but  those  which  are  very  small,  frequently 
yielded  it  in  a  very  unequivocal  manner.  In  one  case,  I  found  it 
very  evident  at  the  junction  of  the  third  rib  with  the  sternum, 
and  in  no  other  part  of  the  chest.  On  examining  the  body  after 
death,  the  lungs  were  found  full  of  tubercles  which,  with  one  ex- 
ception, were  not  yet  completely  softened  :  a  single  excavation,  of 

H  This  statement  is  rather  an  exaggeration.  Pectoriloquy  is  seldom  evident 
in  suoh  cases  ;  but  when  the  patient  attempts  to  speak  we  perceive  a  kind  of 
puff  and  guggling  which  arc  of  equal  value  with  the  true  pectoriloquy. — (M.  L.) 


364  PHTHISIS    PULMONALIS. 

the  size  and  shape  of  a  prune  stone,  existed  in  the  inner  edge  of 
the  lung,  and  corresponded  exactly  with  the  point  of  the  chest 
where  the  pectoriloquy  had  been  perceived.      The  excavations, 
which  are  much  larger  in  one  direction  than  in  another,  and 
are  flattened  by  the  falling  together  of  their  sides,  are  the  least 
proper  for  affording  pectoriloquy,  and  sometimes  do  not  afford  it 
at  all.     This  is  particularly  the  case,  when  an  excavation  of  this 
kind  exists  very  near  the  surface  of  the  lungs,  and  where  the 
pleura,  which  almost  of  itself  forms  its  outer  boundary,  does  not 
adhere  in  this  point  to  the  ribs.     In  examples  of  this  kind,  it  is 
obvious  that  the  thin  outer  wall  of  the  cavity  must  fall  in,  while 
the  patient  is  speaking,  (as   speech  takes  place  only  during  ex- 
piration,)  and   consequently,  that    pectoriloquy   cannot  be    pro- 
duced.    When  there  is  a  great  number  of  excavations  commu- 
nicating with  one  another,  and  producing  a  multitude  of  anfrac- 
tuosities,  the  patient's  voice  is  still  found  to  traverse  the  cylinder, 
but  the   articulation  of  the  words   is  somewhat  smothered  and 
confused.     This  is  almost  always  the  case  when  the  phenomenon 
exists  over  a  great  part  of  the  chest.     Sometimes  even,  as  1  for- 
merly observed,  pectoriloquy  is  more  commonly  suspended  in  ir- 
regular excavations  of  this  kind.     When  pectoriloquy  is  continu- 
ous and  distinct,  and  the  voice  in  traversing  the  cylinder  is  heard 
distinctly  and    articulately,    without    any    rhonchus    or    foreign 
sound  being  perceived  in  the  same  point,  we  must  conclude  that 
the  cavity  is  quite  empty,  and  its  communications  with  the  bron- 
chi large  and  short.     When,  on  the  contrary,  the  sound  is  accom- 
panied with  a  sort  of  guggling,  which  renders  the  articulation  of 
words  less  distinct,  we  are  to  infer  that  the  cavity  contains  a  cer- 
tain quantity  of  tuberculous  matter  of  the  consistence  of  pus.   j 

No  one  of  the  stcthoscopic  results  has  been  more  generally 
verified,  as  well   in   France  as   in  other   parts  of  Europe,  than 
the  uniform  co-existence  of  pectoriloquy  with  ulcerous  excava- 
tions in  the  lungs.     I  shall  not,  therefore,  enlarge  further  on  this 
point.     I  must,  however,  make  one  remark  in  this  place,  which 
may  be  important  to  such  of  my  readers  as  arc  not  much  accus- 
tomed to  dissections  themselves,  or  who  employ  for  this  purpose 
inexperienced  assistants  :  in  the  hurry  of  examination  it  is  quite 
possible  that  no  excavation  may  be   found,  although  one   really 
exists.     This  circumstance  is  of  more  likely  occurrence  when  the 
lung  adheres  firmly  to  the  walls  of  the  chest,  and  the  excavation 
happens  to  be  very  superficial.     In  cases  of  this  kind,  as  the  lung 
can  only  be  detached  by  forcible  detraction,  or  by  the  scalpel,  it 
may  happen  that  either  the  whole  or  the  greater  part  of  the  ex- 
cavation may  be  left  attached  to  the  side  of  the  chest.     A  cir- 
cumstance of  this  kind  occurred  in  an  early  stage  of  my  researches  ; 
and  if  M.  Recamier,  who  assisted  at  the  examination,  (which  was 


PHYSICAL    SIGNS. 


365 


hastily  performed,)  had  not  fortunately  preserved  the  portion  of 
the  detached  limp;,  it  would  not  have  been  ascertained  that  an 
excavation  did  exist  in  the  point  of  lung  over  which  pectoriloquy 
had  been  perceived. 

I  formerly  stated  that  pectoriloquy  sometimes  disappears  en- 
tirely, or  exists  only  very  rarely  and  feebly,  in  excavations  which 
arc  extremely  large,  although  regularly  shaped.  But  in  cases  of 
this  kind,  this  phenomenon  is  replaced  by  two  others  equally 
certain  in  their  indications ;  I  mean  the  cavernous  respiration 
and  metallic  tinJeling.  The  first  of  these  signs  more  particularly, 
is  of  frequent  occurrence.*  Metallic  tinkling  can  only  occur 
when  the  excavation  is  large,  communicating  with  the  bronchi, 
and  containing  only  a  very  small  quantity  of  fluid.  If  there  is 
no  fluid  whatever,  or  next  to  none,  in  the  excavation,  this  phe- 
nomenon will  not  exist ;  but  in  this  case,  the  voice,  the  cough, 
and  respiration,  will  be  accompanied  by  the  utricular  or  amphoric 
resonance.  Pectoriloquy  ceases  entirely,  in  most  cases  at  least, 
when  a  tuberculous  cavity  opens  into  the  pleura.  This  accident 
is  easily  recognized  by  the  signs  of  pneumo-thorax  with  liquid 
effusion,  which  immediately  supervenes,  and  of  which  I  shall 
treat  hereafter.  M.  Louis  has  several  times  remarked,  that  im- 
mediately on  the  perforation  taking  place,  a  violent  pain  is  pro- 
duced in  the  chest,  sufficient  to  call  the  attention  of  the  physician 
to  the  nature  of  the  case.  (A?'chives  de  Med.  1824.)  It  is  no 
doubt  extremely  probable  that  such  a  pain  must  almost  always 
take  place,  since  the  first  effect  of  the  perforation  is  immediately 
to  produce  pleurisy  and  pneumo-thorax ;  but  the  patient  is  very 
likely  to  confound  this  pain  with  his  habitual  sufferings,  and  the 
physician  is  very  likely  to  overlook  it  for  the  same  reason.f     I 

*  Our  author  seems  to  have  taken  less  notice  of  the  state  of  respiration  in  the 
first  stage,  than  it  appears  to  deserve.  In  many  rases,  no  doubt,  as  is  particu- 
larly remarked  by  Andral,  it  is  perfectly  natural,  even  when  there  is  a  nume- 
rous crop  of  tubercles  in  the  lungs ;  and  even  sometimes  when  these  have 
reached  the  state  of  excavation.  In  many  cases,  as  is  also  noticed  by  the  same 
author,  the  respiration  is  puerile,  or  louder  than  natural,  in  different  parts  of  the 
chest,  which  is, probably  owing  to  the  formation  of  many  tubercles  at  the  same 
time,  in  lungs  otherwise  healthy.  This  bind  of  respiration  in  adults  ought 
always  to  excite  suspicion.  In  a  large  proportion  of  instances,  however,  the 
respiration  is  less  than  natural  under  one  or  both  clavicles;  and  if  this  is  the 
case  under  one  clavicle  only,  it  is  a  valuable  sign.  In  these  cases,  we  also  fre- 
quently observe  in  the  same  points,  together  with  a  weak  respiration  and  dimin- 
ished sound  on  percussion,  different  kinds  of  rhonchus, — mucous,  crepitous,  or 
sonorous. —  Transl. 

I  For  an  interesting  account  of  perforation  of  the  lungs,  including  the  detail 
of  seven  cases,  1  refer  the  reader  to  M.  Louis's  Treatise  on  Phthisis,  Chap.  vii. 
p.  446.  This  accident  is  much  more  common  than  is  usually  imagined  :  indeed, 
il  has  been  rarely  taken  notice  of  in  this  country.  It  is,  however."  highly 
deserving  the  attention  of  physicians,  in  relation  both  to  the  prognosis  and 
treatment.  In  M.  Louis's  eases,  the  rupture  of  the  tuberculous  excavation  was 
indicated  by  the  instantaneous  supervention  of  an  acute  pain  in  one  point  of  the 
chest,  with  dyspnaa  and  extreme  anxiety;  which  symptoms  were  followed  by 


366  PHTHISIS    PULMONALIS. 

shall  conclude  the  section  with  two  cases  of  very  large  tubercu- 
lous excavations  indicated  by  the  metallic  tinkling. 

Case  XXVII.  Tuberculous  cavity  partly  converted  into 
fistula,  producing  metallic  tinkling. — A  woman,  fifty  years  of 
age,  who  had  been  affected  with  cough  and  expectoration  for  se- 
veral years,  and  which  had  got  much  worse  within  a  few  months 
past,  came  to  the  Necker  Hospital  on  the  13th  April,  1819, 
having  for  the  first  time,  been  obliged  to  desist  from  her  ordi- 
nary occupation.  She  looked  much  older  than  she  was,  and 
was  very  thin.  The  pulse  was  quick,  skin  slightly  hot,  and  the 
expectoration,  which  was  in  moderate  quantity,  consisted  of  thick 
yellow  sputa  intermixed  with  much  transparent  ropy  mucus. 
The  stethoscope,  applied  to  the  anterior,  and  upper  part  of  the 
right  side,  and  to  the  right  axilla,  detected  distinct  pectoriloquy, 
and  in  the  same  places,  when  the  patient  coughed  or  spoke,  and 
still  more  during  respiration,  there  was  heard  a  tinkling,  like  that 
of  a  small  bell  which  has  just  stopped  ringing,  or  of  a  gnat  buz- 
zing within  a  porcelain  vase.  A  mucous  rhonchus  or  strong 
guggling  existed  in  the  same  points ;  and  all  these  phenomena 
were  distinctly  perceptible  over  the  whole  space  from  the  top  of 
the  shoulder  to  the  fourth  rib, — being  only  more  distinct  ante- 
riorly, and  under  the  axilla,  than  behind.  The  respiration  was 
sufficiently  distinct  over  the  greater  part  of  the  chest,  except  at 
the  roots  of  the  right  lung,  and  the  top  of  the  left,  where  it  was 
scarcely  perceptible.  The  Hippocratic  succussion  afforded  no 
result.  From  these  various  signs  I  made  the  following  diagnosis : 
Vast  tuberculous  cavity  occupying  the  whole  of  the  superior  lobe 

the  usual  signs  of  acute  pleurisy,  terminating  in  death  within  a  period  varying 
from  one  day  to  thirty-six.  In  one  case  only,  was  there  no  pain ;  but  the  acci- 
dent was  pointed  out  by  the  instantaneous  supervention  of  extreme  dyspnoea 
and  anxiety.  In  every  case  of  this  kind,  the  diagnosis  founded  on  the  common 
symptoms,  derives  unerring  certainty  from  auscultation  and  percussion.  In 
five  of  the  cases  detailed  byM.  Louis,  the  perforation  occurred  in  the  same  point, 
viz.  opposite  the  angle  of  the  third  or  fourth  rib  of  the  left  side  ;  and  I  may  add 
that,  in  the  case  of  a  young  gentleman  whom  I  recently  attended,  and  who 
survived  the  accident  only  four  days,  the  rupture  took  place  precisely  in  the 
same  spot. —  Transl.  • 

When  a  pleuritic  effusion  opens  into  the  bronchi,  a  bruit  dr,  craquement  is 
sometimes  heard,  as  shown  by  the  following  case  published  by  Dr.  Lecomte. 
A  man  aged  thirty-two,  entered  La  Charite  Hospital  with  pain  in  the  side,  hav- 
ing been  sick  seventeen  days.  On  examining  the  chest  it  yielded  a  flat  sound, 
and  the  respiratory  murmur  was  completely  wanting  in  the  lower  part  of  its 
right  side  ;  humid  rattles  were  heard  in  the  upper  part  of  the  right  lung  ;  soon 
after,  these  rattles  were  heard  throughout  the  whole  side.  M.  Chomel,  under 
whose  care  the  patient  happened  to  be,  suspected  a  communication  between  the 
bronchi  and  the  pleura,  and  thought  it  possible  that  a  large  quantity  of  pus 
might  be  expectorated.  In  fact  the  next  day,  the  patient,  after  severe  fits  of 
coughing,  discharged  a  quantity  of  greyish,  opaque  matter,  of  an  insupportable 
stench.  Then  came  on  the  amphoric  respiration  and  metallic  tinkling,  yet  the 
patient  recovered  in  about  four   months. 

Is  it  quite  certain  that  in  this  case  there  was  any  effusion  in  the  pleura?  Was 
it  not  an  instance  of  gangrene  of  the  hms?—Jlndral. 


PHYSICAL    SIGNS.  367 

of  the  right  lung,  and  containing  a  small  quantity  of  fluid :  tu- 
bercles, especially  at  the  top  of  the  left  and  root  of  the  right  lung. 
Four  days  after  her  entry  this  woman  was  discharged  for  irregu- 
larity. She  came  into  the  hospital  again  in  the  end  of  May,  af- 
fected with  precisely  the  same  symptoms.  She  died  suddenly 
on  the  6th  of  June. 

Dissection   twenty-four   hours  after  death. — On  penetrating 
with  the  scalpel  between  the  fourth  and  fifth  ribs  of  the  right 
side  a  small  quantity  of  air  escaped.*     The  lungs  on    this  side 
were    flattened    from   within    outwards   towards    the    ribs,  and 
adhered    throughout    to   the    pleura   of  the    ribs,    mediastinum 
and    diaphragm.      Above  the   sixth  rib  the   adhesion  was  very 
close.     The  upper  half  of  this  lung  was  occupied  by  a  vast  tu- 
berculous cavity,  which  contained  about  two  spoonfuls  of  a  puru- 
lent fluid.     The  parietes  of  this  excavation  (except  on  the  lower 
side)    consisted  of  condensed  pulmonary   tissue,    surrounded  by 
a  thin  layer  of  a  fibrous   texture  like   the  lateral  ligaments  of  the 
joints,  which  was  intimately  connected   with  the  pleura  of  the 
ribs  and  lungs.     The  main  cavity  was  large  enough  to  contain 
the  hand  of  the  largest  man,  and  branched  out  into  many  anfrac- 
tuosities :  it  was  crossed  at  one  point  by  a  band  of  flaccid  pul- 
monary tissue,  pretty  healthy,  and  covered  by  the  lining  mem- 
brane of  the  excavation.      Here  and  there  blood-vessels  of  the 
size  of  a  crow-quill  ramified  on  the  interior  of  this,  some  adhe- 
rent, and  others  partially  detached,  some  quite  obliterated,  others 
only  partially.     A  semi-cartilaginous  membrane,  extremely  un- 
even and  of  very  variable  thickness,  lined  the  cavity  throughout ; 
and  this  was  the  only  boundary,  on  the  inferior  part,  between  it 
and  a  branch  of  the  pulmonary  artery  large  enough  to  admit  the 
little  finger.      The  anterior  part  of  this  excavation  terminated  in 
a  longish   cul-de-sac,  which  was  lined  by  a  membrane  entirely 
cartilaginous,  and  much  thicker  than  that  of  the  other  parts  of 
it.     In  cutting  this  part  of  the  lung  from  above  downwards,  we 
could  trace  this  cartilaginous  lining  under  the  form  of  a  lamina 
of  cartilage  for  more  than  an  inch  into  the  substance'of  the  lung 
beyond  the  walls  of  the  excavation.     This  was  no  doubt  the  re- 
maining cicatrice  of  a  cavity  which  had  communicated  with  that 
which  existed  at  present.     Some  bronchial  tubes  that  stretched 
towards  this   lamina  terminated  in  culs-de-sac  before  reaching  it, 
still,  however,  retaining  a  considerable  calibre,  and  having  their 
mucous    membrane    very  red    and    thickened.      Several    other 
branches  of    the  bronchi  opened  into  the  existing  cavity,  with 
their  terminations  quite  smooth  and  polished.     The  anterior  por- 

Tliis  must  have  come  from  the  excavation  which  will  be  immediately  no- 
ticed, as  thecavity  of  the  pleura  was  obliterated. — iiukor. 


368  PHTHISIS    PULM0NAL1S. 

tion  of  the  superior  and  middle  lobes,  which  had  not  been  impli- 
cated in  this  destruction,  was  still  crepitous,  and  contained,  in 
different  parts,  small  groups  of  tubercles  in  different  stages,  as  did 
also  the  lower  lobe. 

On  puncturing  the  left  side  of  the  chest  there  was  an  escape  of 
gas,  which  must  have  come  from  the  cavity  of  the  pleura.  There 
was  no  effusion  in  this  side  of  the  chest,  and  the  greater  part  of 
the  lung  was  unattached,  except  at  its  very  upper  point.  This 
was  strongly  attached  to  the  costal  pleura  by  a  very  thick, 
whitish,  fibrous  membrane,  covering  a  sort  of  cartilaginous  Cica- 
trice in  the  lung,  of  two  or  three  lines  in  thickness,  which  sur- 
mounted an  irregular  cavity  of  the  size  of  a  pigeon's  egg.  The 
walls  of  this  were  formed  by  a  condensed  pulmonary  substance, 
and  inclosed  a  small  calcareous  concretion.  The  remaining  parts 
of  this  lung  were  pretty  sound,  only  containing  some  tubercles. 

Case  XXVIII.  Tuberculous  excavation  producing  the  me- 
tallic tinkling. — A  woman,  aged  forty,  came  into  the  Necker 
Hospital  29th  January,  1818,  having  been  affected  with  cough 
for  five  months,  and  which  had  increased  since  her  confinement 
three  months  before.  At  this  time  the  respiration  was  short  and 
■■  quick,  and  difficult;  the  chest  sounded  pretty  well  on  the  back 
and  left  side  before, — but  better  on  the  right  side  ;  there  was 
distinct  pectoriloquy  near  the  junction  of  the  sternum  and  left 
clavicle,  and  the  same  phenomenon,  but  less  distinct,  on  the  same 
side  where  the  arm  joined  the  chest ;  the  sound  of  the  ventricles 
was  dull,  and  the  heart  gave  hardly  any  impulse.  Two  days 
after,  by  means 'of  the  cylinder,  we  distinguished  a  sound  resem- 
bling fluctuation,  in  the  left  side,  when  the  patient  coughed,  and 
the  metallic  tinkling  when  she  spoke.  Succussion  of  the  trunk 
did  not  produce  the  sound  of  fluctuation.  From  these  results 
the  following  diagnostic  was  given  :  Very  large  tuberculous  exca- 
vation in  the  middle  of  the  left  lung,  containing  a  small  quan- 
tity of  very  liquid  matter.     The  patient  died  five  days  after  this. 

Dissection  twenty-four  hours  after  death. — In  the  right  lung 
through  its  whole  extent,  there  were  innumerable  tubercles  of  a 
yellowish  white  color,  and  varying  in  size  from  that  of  a  hemp- 
seed  to  a  cherry-stone,  and  even  a  large  filbert.  These  last 
were  evidently  formed  by  the  reunion  of  several  smaller  ones, 
and,  for  the  most  part,  were  more  or  less  softened.  Besides  these, 
there  were,  in  other  parts,  several  cavities,  the  largest  of  which 
would  have  contained  a  hazel  nut,  completely  filled  by  pus, 
thicker  than  that  of  an  abscess,  and  lined  by  a  double  membrane, 
the  inner  layer  of  which  was  white,  soft,  and  a  little  adherent  to 
the  other  ;  the  outer  was  of  a  cartilaginous  character  and  semi- 
transparent,  and  incomplete  in  certain  points.  The  left  lung 
adhered  closely  to  the  pleura  of  the  ribs  and  pericardium.     On 


SYMPTOMS    AND    PROGRESS. 


369 


its  anterior  and  lateral  part  it  contained,  near  its  surface,  three 
cavities,  one  above  the  other,  and  communicating  by  two  large 
openings.  The  upper  of  the  size  of  a  pigeon's  egg,  occupied 
-the  top  of  the  lung,  and  corresponded  to  the  junction  of  the  cla- 
vicle and  sterum ;  the  second  might  have  contained  a  pullet's 
egg,  and  the  lowest,  which  reached  within  an  inch  of  the  base  of 
the  lung,  was  of  the  size  of  a  walnut.  These  excavations  were 
lined  by  two  membranes,  like  those  in  the  right  lung,  containing 
a  liquid  pus,  and  communicated  with  several  bronchial  tubes. 
This  lung  contained  also  some  smaller  cavities  and  tubercles, 
and  exhibited  marks  of  inflammation  in  various  places.* 

Sect.  VI. — Symptoms  and  progress  of  phthisis. 

Although  characterized  in  its  latter  stages  by  very  marked 
symptoms,  phthisis  pulmonalis  is  extremely  variable  in  its  onset, 
and  in  many  cases  it  is  difficult  to  recognize  it  from  its  symptoms 
only,  in  any  part  of  its  course.  With  a  view  to  its  more  correct 
discrimination,  I  shall  consider  it  under  five  different  forms  or 
varieties. 

1.  Regular  manifest  phthisis, — phthisis  of  the  ancients. — 
Distinct  and  manifest  phthisis  frequently  begins  with  a  slight  dry 
cough,  which  might  be  readily  mistaken  for  the  effect  of  a  dry 
catarrh.  It  was  no  doubt  the  observation  of  this  seeming  catarrh 
preceding  the  disease,  that  led  the  ancients  to  attribute  consump- 
tion to  it.  And  this  opinion  must  have  appeared  probable,  be- 
fore the  progress  of  pathological  anatomy  had  discovered  the  ex- 
istence of  miliary  tubercles  in  the  lungs  previous  to  every  local 
or  general  symptom  of  the  disease.  This  kind  of  cough  may 
last  several  months,  or  sometimes  even  several  years,  without  any 
other  accompanying  symptom  ;  and  if  at  this  period  the  patient 

*  I  think  it  highly  necessary,  in  this  place,  to  caution  the  student  against 
yielding  too  implicit  confidence  to  auscultation  and  percussion  as  means  of  diag- 
nosis, to  the  neglect  or  exclusion  of  the  more  usual  methods.  It  is  no  doubt 
true,  that  these  measures  are  of  the  very  first  importance  in  the  diagnosis  of 
this,  as  of  almost  every  other  disease  of  the  chest;  that  in  many  cases  they 
alone  suffice  to  fix  the  diagnosis  ;  and  that  in  others  this  cannot  be  established 
without  them  ;  at  the  same  time,  it  is  equally  certain,  that  if  we  attempt,  as  our 
general  practice,  to  draw  our  conclusions,  from  these  signs  alone,  without 
reference  to  the  local  and  general  symptoms,  we  shall  frequently  not  merely  fail 
to  attain  our  object  at  all,  but  we  shall  run  great  risk  of  falling  into  errors  of  the 
most  serious  nature.  It  is  only  by  combining  the  practice  of  auscultation  with 
the  faithful  observation  of  symptoms,  and  by  studying  the  results  obtained  from 
both  sources,  with  a  reference  to  the  pathology  of  the  disease,  that  we  can  hope 
to  attain  such  a  certainty  of  diagnosis  as  can  satisfy  a  philosophical  mind.  I 
dwell  the  more  upon  this" point,  on  the  present  occasion,  as  pectoriloquy  is  one 
of  the  results  of  auscultation  most  likely  to  impress  strongly  the  mind  of  the 
student,  and  because  I  am  of  opinion  that  our  author  lays  more  stress  on  it  than 
ir  deserves.  Though  very  valuable,  I  confess  that  it  is  far  from  being,  in  my 
nation,  the  most  valuable  of  the  stethoscopic  signs.—  Transl. 
47 


370  PHTHISIS     PULMONALIS. 

should  chance  to  die  of  any  other  disease,  the  lungs  will  be  found 
crowded  with  very  small  tubercles,  almost  all  of  which  are  still 
entirely  grey  and  semi-transparent.  It  is  to  be  observed,  how- 
ever, that  when  tubercles  remain  long  in  this  state,  it  is  much 
more  common  for  them  to  occasion  an  abundant  pituitous  ex- 
pectoration, as  was  remarked  by  Bayle.*  Sometimes  the  disease 
begins  (during  the  very  best  health  apparently,  or  after  some 
slight  disorder  not  well  accounted  for)  with  an  acute  catarrh,  of 
which  we  are  at  the  time,  far  from  considering  tubercles  as  the 
cause.  Pretty  frequently  an  haemoptysis,  more  or  less  severe,  is 
the  first  sign  of  the  disease.     This   sign,  however,  is  never  cer- 

*  The  cough  connected  with  tubercles  in  the  lungs  is  not  always  dry  at  first : 
it  is  not  uncommon  to  find  phthisical  persons  who  affirm  that  from  the  beginning 
of  the  cough  they  had  mucous  expectoration  more  or  less  plentiful.  This 
dry  cough  in  the  beginning  of  phthisis  has  no  more  necessary  connection  with  a 
real  bronchitis  than  the  dry  cough  of  pleurisy.  Further,  it  seems  to  me  clearly 
proved  that  tubercles  may  exist  in  the  lungs  long  before  any  cough  occurs. 
Nevertheless,  in  some  cases,  tubercles  may  seem  to  form  only  after  a  bronchitis 
remarkable  for  intensity  or  duration.  In  the  first  instance,  no  perceptible  irrita- 
tion of  the  bronchi  preceded  the  formation  of  tubercles:  in  the  second,  this 
irritation  appears  to  be  the  occasional  cause  of  their  development. 

It  is  seldom  that  the  cough  provoked  by  the  presence  of  tubercles  in  the 
lungs,  has  no  intervals  of  perfect  quiet.  We  often  observe,  for  example,  individ- 
uals undoubtedly  tuberculous,  whose  cough  is  thus  suspended  for  several  months 
together  :  it  re-appears  in  winter,  and  goes  off  in  summer,  to  return  again  with 
cold  weather.  In  other  phthisical  persons  the  cough  comes  on  in  the  heat  of 
summer :  it  is  less  common  and  less  painful  with  these  individuals  in  October 
than  in  July.  After  a  suspension  it  comes  on  again  with  remarkable  facility 
under  the  influence  of  slight  causes.  The  mildest  cold,  loud  talking,  mental 
anxiety  or  fatigue  will  bring  it  on  immediately,  and  the  oftener  it  is  recalled  by 
these  causes,  the  more  difficult  it  is  to  remove  it,  till  at  last  it  becomes  perma- 
nently established. 

There  are  many  others  in  whom  the  cough  is  not  thus  intermittent,  but  hav- 
ing once  appeared  never  ceases.  In  these  cases  the  progress  of  the  disease  is 
commonly  much  more  rapid. 

In  some  patients  the  cough  is  slight  and  is  hardly  perceptible.  Some  are  so 
little  incommoded  by  it  that  they  will  not  allow  they  have  a  cough.  All  they 
are  able  to  discover  in  themselves  of  this  character  is  a  titillation  of  the  larynx, 
which  causes  from  time  to  time  a  slight  effort  at  coughing,  and  they  persist  in 
saying  they  have  no  cold  nor  have  had  any  :  thus  they  may  die  with  hardly 
any  cough,  or  at  least  without  enough  of  it  to  attract  the  attention  either  of  the 
patient  or  physician.  Among  others,  on  the  contrary,  the  cough  is  one  of  the 
predominant  phenomena :  it  is  perpetually  occuring  in  painful  paroxysms,  or  it 
is  a  small  dry  cough,  incessant,  and  very  fatiguing  to  the  patient.  Among  other 
cases  I  have  seen  a  young  female,  for  a  long  time  regarded  as  consumptive,  yet 
prolonging  her  existence  without  any  appearance  of  immediate  danger.  Towards 
the  end  of  a  winter  which  she  had  passed  in  good  health,  she  was  suddenly  at- 
tacked with  a  dry  cough  which  for  three  months  was  incessant.  During  this 
long  space,  five  minutes  did  not  pass  without  coughing.  The  cough  was  sono- 
rous and  loud,  and  seemed  to  be  altogether  in  the  larynx.  Its  characteristics 
were  such  that  at  first  it  was  not  unreasonable  to  suppose  it  to  be  the  effect  of 
a  simple  neurosis,  seated  probably  in  the  larynx.  Under  this  impression,  the 
usual  remedies  in  such  cases  were  administered:  all  \va<  in  vain;  blood  letting 
had  no  better  effect,  and  gradually  without  any  change  in  the  character  of  the 
cough,  divers  symptoms  appeared  which  left  no  doubt  of  pulmonary  phthisis, 
nearly  latent  hitherto  but  now  suddenly  assuming  a  more  acute  aspect,  and 
death  ensued  speedily. — Andral. 


SYMPTOMS    AND    PROGRESS. 


371 


tain :  and  in  this  stage  of  the  complaint,  the  haemorrhage  may 
return  repeatedly,  after  an  interval  of  weeks  or  months,  without 
affording  any  positive  proof  of  the  existence  of  tubercles.* 

In  whatever  way  the  disease  commences,  a  more  or  less  abun- 
dant mucous  expectoration,  and  a  constant  state  of  feverishness 
gradually  supervene.  This  fever  has  commonly  two  accesses, 
the  one  a*bout  noon,  and  the  other  about  the  beginning  or  middle 
of  the  night.  Sometimes  it  is  attended  at  the  beginning  by 
chills,  which  return  with  the  tertain  double  tertain,  or  quotidian 
type  ;  and  it  is  by  no  means  very  unusual  to  find  phthisis  deve- 
loping itself  during  the  course  of  an  intermittent  fever .f     Towards 

*  Taken  singly,  haemoptysis  is  no  doubt  a  very  uncertain  sign  of  the  existence 
of  tubercles  ;  but  when  showing  itself  with  several  other  symptoms,  not  more 
certain  in  themselves,  it  adds  extremely  to  the  probability  of  the  case. —  Transl. 

The  haemoptysis  connected  with  the  existence  of  tubercles  in  the  lungs 
may  appear  at  different  stages  of  the  affection,  and  be  accompanied  and  followed 
by  very  different  symptoms.  There  are  cases,  and  these  are  not  few,  in  which 
the  haemoptysis  takes  place  at  a  time  when  the  health  appears  good,  and  when 
at  the  most,  according  to  the  constitution  of  the  patient,  there  may  be  a  vague 
suspicion  of  some  tubercles  in  the  parenchyma  of  the  lungs.  After  the  first 
spitting  of  blood  it  may  happen  that  health  is  restored,  and  for  a  long  time  the 
patients  show  no  symptom  of  a  serious  malady ;  they  have  no  cough,  and  the 
chest  retains  no  traces  of  the  accident  they  have  suffered.  But  after  a  while,  a 
second  haemoptysis  takes  place,  then  a  third,  and  between  these  the  health  may 
also  be  good.  Yet  in  attentively  observing  the  patients,  we  discover  gradually, 
and  in  proportion  as  the  spitting  of  blood  is  repeated,  that  they  lose  flesh  and 
strength,  the  face  becomes  of  a  peculiarly  pale  complexion;  they  begin  to 
cough,  and  complain  of  taking  cold  with  remarkable  facility  ;  they  are  often 
surprised  to  find  their  breathing  grow  short  and  embarrassed,  at  length  comes  a 
new  haemoptysis,  after  which  they  remain  decidedly  worse,  or  without  any  re- 
turn of  the  haemoptysis  they  take  another  cold,  heavier  than  the  preceding, 
which  fatigues  them  mofe,  and  leads  them  insensibly  into  a  phthisis.  I  knew 
an  old  man,  who,  after  having  for  thirty  years  had  frequent  attacks  of  haemop- 
tysis without  his  health,  though  habitually  feeble,  appearing  to  be  seriously  af- 
fected by  them,  at  last  died  of  consumption  at  sixty-six.  I  have  known  others 
who,  after  having  had  in  early  youth  an  attack  of  haemoptysis,  which  did  not 
re-appear,  passed  their  lives  without  any  serious  pectoral  affection  till  40,  50,  or 
60,  when  symptoms  of  pulmonary  phthisis  appeared.  Another  old  man  had 
between  the  age  of  20  and  80,  haemoptysis  perpetually  recurring,  and  died  after- 
wards of  a  disease  not  connected  with  the  lungs.  He  had  always  been  in  what 
is  called  delicate  health;  for  many  years  he  had  hardly  passed  a  winter  without 
taking  cold  ;  his  breath  had  always  been  short,  yet  he  had  been  able  to  pass  a 
long  life  without  suffering  any  interruption  of  his  ordinary  occupation  till  he 
was  suddenly  taken  with  a  spitting  of  blood.  This  old  man  had  several  chil- 
dren (which  is  not  the  least  remarkable  of  these  circumstances)  who  all  died 
of  pectoral  complaints  in  early  life,  having  also  all  suffered  from  haemoptysis. 
On  opening  the  body,  a  great  number  of  cretaceous  tubercles  were  found,  sur- 
rounded by  portions  of  black  and  indurated  pulmonary  tissue;  no  traces  were 
found  of  cavities  cither  old  or  recent. — Indral . 

t  I  doubt  whether  the  development  of  phthisis  during  the  course  of  an  inter- 
mittent fever  has  been  witnessed  so  often  as  Laennec  here  affirms.  What  ap- 
pears to  me  more  common  is,  to  see  paroxysms  of  fever,  which  are  commonly 
taken  for  ordinary  intermittent  fever,  and  therefore  are  treated  with  preparations 
of  bark,  display  themselves  at  the  time  of  tuberculous  affections  of  the  lungs  not 
yet  well  defined,  and  apparent  only  by  slight  local  symptoms.  The  mere  soft- 
ening of  a  tuberculous  mass  often  causes  those  febrile  paroxysms.  In  such 
cases  it  happens  very  often  that  the  bark  removes  the  shivering  with  which 
they  commence,  but  it  has  no  power  over  the  fever,  and  must  soon  after  be 
abandoned. — Andral. 


372  PHTHISIS     PULM0NALI9. 

morning,   perspirations  come  on :  and   these  are   sometimes  so 
enormous  as   to  wet  two  or  three  matresses  in  the  course  of  a 
single  night.*     However  intense  this  hectic  fever  may  be,  (and 
judging  from  the  frequency  of  the  pulse  and  heat  of  the  skin,  it 
is  sometimes  very  great,)  it  is  hardly  ever  accompanied  by  many 
of  the  severer  symptoms  which  we  frequently  observe  in  idiopa- 
thic fevers,  having  the  two  symptoms  just  mentioned  in  a  much 
less  degree.     In  the  symptomatic  fever  of  consumption,  the  head 
is  free ;  the   respiration   is   sometimes  scarcely   shorter   than   in 
health ;  the  digestive  functions  are  frequently  in  a  state  of  per- 
fect integrity ;  and  even  the  muscular  strength  does  not  fail  for  a 
long  time, — and  when  it  does  give  way,  it  appears  to  be  owing 
rather  to  the  excessive  evacuations,  than  to  the  severity  of  the 
fever.     To   the  colliquative  sweats,  a  diarrhoea  no  less  debilita- 
ting supervenes,  and  rapidly  wastes  the  patient's  strength-!     ^n 
females  the  catamenia  are  almost  always  suppressed  shortly  after 
the  development  of  the  fever,  and  sometimes  even  previously  to 
any  obvious  symptom  of  disease.     In  these  latter  cases,  the  vul- 
gar, and   even  physicians   themselves,  take  advantage  of   their 
favorite  axiom — post  hoc,  ergo  propter  hoc, — and  attribute  the 
consumption   to  the  suppression ;  although  the  fact  is,  that  this, 
in  the  majority  of  cases,  is  only  the  effect  of  the  development  of 
tubercles  in  the  lungs.J     As   soon  as   the   hectic  fever  is  estab- 
lished, wasting  of  the  body  becomes  manifest,  and  makes  more 
rapid  progress,  according  as  the  perspiration,  the  expectoration 
and  the  diarrhoea  are  more  abundant.      In  women  and  persons 
of  a  lymphatic  habit,  the    skin  becomes    white    or  bluish-pale, 
with  a  very  slight  shade  of  lemon-yellow.     The  emaciation  then 
makes  rapid  progress   towards  complete  marasmus  ;  and  presents 
to  us  the  picture   traced  with   such  frightful    truth  by  Aretaeus. 
The  nose  becomes  sharp  and  drawn  ;  the  cheeks  are  prominent 
and  red, — and  appear  redder  by  contrast  with  the  surrounding 
paleness  ;  the   conjunctiva  of  the  eyes  is  of  a  shining  white  or 
with  a   shade   of  pearl-blue ;  the   cheeks   are   hollow ;  the  lips 
are  retracted,  and  seem  moulded  into  a  bitter  smile  ;  the  neck 
is  oblique,  and  impeded  in  its  movements ;  the  shoulder-blades 

*  The  sweating,  though  it  exists  in  an  immense  majority  of  cases  as  marking 
the  most  advanced  stage  of  pulmonary  phthisis,  yet.  it  may  sometimes  be  want- 
ing. In  repeated  cases,  I  have  found  the  lungs  full  of  cavities,  yet  the  patient 
had  no  increase  of  cutaneous  exhalation  up  to  the  time  of  his  death.  It  may  also 
happen,  and  this  is  very  common,  that  after  being  very  abundant,  the  perspira- 
tion diminishes  and  is  even  suspended,  and  re-appears  without  any  perceptible 
cause  for  such  an  irregularity. —Jlndral. 

t  This  diarrhoea  is  commonly  occasioned  By  a  secondary  eruption  of  tubercles 
in  the  intestinal  tunics  ;  sometimes  it  arises  without  these,  and  even  without  any 
ulceration  or  inflammation  of  the  intestines.— Author. 

X  See  Morton's  Phthisiologia,  Lib.  ii.  Cap.  ix.  "  De  Phthisi  achlorosi  et  sup- 
pressione  menstruarum  purgationum  orta. "—  Transl. 


SYMPTOMS    AND    PROGRESS.  373 

are  projecting  and  winged ;  the  ribs  become  prominent,  and  the 
intercostal  spaces  sink  in,  particularly  on  the  upper  and  fore 
parts  of  the  chest.  Sometimes  even  the  whole  chest  seems  con- 
tracted, as  was  observed  by  Bayle  ;  and  this  may  actually  be  the 
case,  particularly  when  the  disease  is  very  chronic,  owing  to  the 
contraction  and  tendency  to  cicatrization  of  large  tuberculous 
excavations.  The  belly  is  flat  and  retracted  ;  the  larger  joints 
and  those  of  the  fingers,  appear  enlarged  from  tlje  falling  away 
of  the  neighboring  soft  parts  ;  and  even  the  nails  become  in- 
curvated,  in  consequence  of  the  absorption  of  the  pulpy  extre- 
mities of  the  fingers.  No  other  disease  gives  rise  to  so  complete 
emaciation  as  phthisis, — except  cancer  and  continued  fever  of 
long  duration.* 

But  neither  this  degree  of  emaciation  nor  the  other  symptoms 
just  enumerated,  are  in  all  cases  proofs  of  an  incurable  disease. 
I  have  already  noticed  (Cases  XXV.  and  XXVI.)  two  instances 
of  cure  after  the  patients  had  been  reduced  to  the  most  extreme 
degree  of  emaciation.  But  death  may  take  place  long  before 
the  disease  has  produced  this  degree  of  wasting.  After  the 
supervention  of  the  hectic  fever  and  expectoration,  the  course  of 
the  disease  varies  in  general  very  little :  its  uniform  progress 
towards  a  fatal  termination  being  only  hastened  by  the  occasional 
increase  of  the  perspirations  or  diarrhoea.  In  this  stage  of  the 
disease,  haemoptysis,  to  any  extent  is  very  uncommon.  Now  and 
then  there  only  appear  a  few  streaks  of  blood  in  the  expectora- 
tion ;  and  indeed  the  greater  number  of  patients,  and  even  those 
who  had  severe  haemorrhage  at  the  beginning,  exhibit  no  traces 
of  it  whatever.  Pretty  often,  at  the  period  when  the  complete 
evacuation  of  a  tuberculous  cavity  is  indicated  by  the  stetho- 
scopic  signs,  the  patient  experiences  a  marked  improvement  in 
his  symptoms  ; — the  expectoration  and  fever  decrease,  and  if  the 
improvement  only  lasts  a  little  while,  even  the  wasting  of  the 
body  is  sometimes  diminished.  This  false  convalescence  is  usu- 
ally only  of  a  few  days'  or  weeks'  duration  ;  but  it  may  extend  to 
some  months,  and  may  even  seem  to  be  complete.  I  have  noticed 
above  a  remarkable  instance  of  this  kind  of  deceptive  cure.  We 
shall  immediately  see  that  in  the  chronic  cases,  it  may  last  for 
years ;  and  as  has  been  already  proved  (Cases  XXV.  and 
XXVI.)  it  may  even  in  some  rare  instances,  terninate  in  a  per- 

*  There  are,  I  think,  few  cases  in  which  cancer,  wherever  situated,  produces 
an  emaciation  equal  to  that  of  pulmonary  phthisis,  when  it  passes  through  all 
its  stages,  and  the  patient  is  not  prematurely  carried  off  by  an  intermittent  affec- 
tion, a  thing  very  common.  Cancer  in  the  stomach  causes  eventually  the 
greatest  emaciation.  A  certain  degree  of  corpulence,  on  the  ether  hand,  some- 
times! attends  cancer  of  the  uterus:  and  it  is  not  uncommon  to  see  the  coun- 
tenances of  females  preserving  their  full  shape  when  the  fatal  progress  of  this 
disease  had  completely  destroyed  the  neck  of  the  uterus. — An&ral. 


374  PHTHISIS    PULMONALE. 

feet  and  permanent  restoration  of  health.  In  attentively  follow- 
ing the  progress  of  phthisis  in  a  certain  number  of  subjects,  we 
shall  find  that  there  is  hardly  one  of  them  that  does  not  present 
some  signs  of  amendment  at  the  period  when  the  cavernous 
rhonchus  and  respiration  indicate  the  complete  or  nearly  com- 
plete destruction  of  the  primary  tuberculous  masses  ;*  and  that 
the  return  of  the  general  symptoms  in  their  primitive  intensity, 
is  more  or  less*apid,  according  as  the  tubercles  of  the  secondary 
eruptions  are  more  or  less  advanced  in  their  progress.  We  shall 
likewise  observe  that  the  cases,  in  which  convalescence  becomes 
apparently  confirmed  and  lasts  several  months,  are  those  in 
which  the  secondary  eruptions  do  not  take  place  until  after  the 
complete  softening  of  the  first  crop  of  tubercles.  I  am  convinced, 
by  experience,  that  in  the  greater  number  of  cases,  eruptions  ot 
this  kind  take  place  at  an  earlier  period,  and  especially  at  the 
time  when  the  primary  tubercles  begin  to  soften.  The  cases  of 
complete  cure  are  evidently  those  in  which  the  secondary  erup- 
tion does  not  take  place  at  all. 

The  stethoscopic  signs  afford  the  only  certain  means  by  which 
we  can  recognize  the  softening  of  the  tuberculous  matter  and  its 
discharge  into  the  bronchi.  We  seldom  derive  any  assistance 
from  the  local  symptoms,  in  this  respect.  Sometimes  only,  we 
observe  a  few  streaks  of  blood  in  the  expectoration  at  the  time 
when  the  matter  makes  its  way  into  the  bronchi,  and  it  is  ex- 
tremely rare  to  find  distinct  portions  of  tuberculous  matter  in  the 
expectoration. — In  general  nothing  is  more  uncertain  than  the 
local  pains  in  this  disease  :  most  of  the  patients  have  some  pain  ; 
many  have  none  at  all ;  and  some  have  very  acute  pain,  occa- 
sioned either  by  the  supervention,  from  time  to  time,  of  slight 
pleurisies  or  peripneumonies,  or  by  simple  neuralgia,  unaccom- 
panied by  any  mark  of  inflammation.!     In  some  cases  the  patients 

*  Some  patients  may  be  thus  situated,  and  justify  the  assertion  of  Laennec  ; 
but  taken  in  general, "the  assertion  appears  to  be  incorrect,  and  I  think  1  can 
say  that  in  most  cases  on  the  contrary,  the  actual  formation  of  the  cavities  is 
attended  with  a  general  aggravation  of  the  symptoms,  and  that  the  cases  in 
which  phthisis  is  arrested,  or  suspended  at  this  point,  are  certainly  the  most 
rare. — Jlndral. 

t  The  numerous  cellular  adhesions  which  in  phthisical  subjects  connect  the 
costal  and  pulmonary  pleura,  are  commonly  formed  without  pain,  yet  some- 
times the  patient  complains  of  a  sharp  continued  pain  in  a  part  of  the  chest, 
which  often  lasts  long  without  means  being  effectual  either  to  remove  or  dimin- 
ish it;  at  other  times  the  pain  may  be  removed  by  leeches  or  cupping  or  blis- 
tering. Other  phthisical  patients  complain  of  vague  wandering  pains  in  diffe- 
rent parts  of  the  chest,  to  which  they  give  little  attention,  because  they  take 
them  for  nervous  or  rheumatic  pains.  Some  of  these  persons  complain  distinctly 
of  a  painful  sensation  or  sort  of  habitual  oppression  in  that  part  of  the  lungs 
where  the  stethoscope  discovered  the  most  advanced  lesion,  and  particularly 
under  the  clavicle  ;  others  distinguish  clearly  the  point  from  which  the  blood 
and  expectoration  proceed.  Those  who  have  severe  bronchitis  complain  often 
of  no  other  pain  than  a  burning  or  pricking  sensation,  more  or  less  painful 


SYMPTOMS    AND    PROGRESS. 


375 


are  sensible  of  the  guggling  of  the  softened  tuberculous  matter, 
and  can  point  out  the  spot  whence  their  expectoration  comes. 
This,  however,  is  very  unusual  ;  and  we,  on  the  other  hand,  meet 
with  many  others  who  suffer  most  pain  in  the  parts  of  the  lungs 
which  are  the  soundest.* 

Notwithstanding  the  efforts  which  have  been  made,  in  all  ages, 
to  deduce  pathognomonic  signs  from  the  appearance  of  the  expec- 
toration in  phthisis,  it  must  be  confessed  that  this  affords  no 
peculiar  characters  which  are  not  met  with  in  the  sputa  of  chronic 
catarrh.  And  modern  chemistry  has  thrown  no  new  light  on  the 
subject.  Three  different  kinds  of  matter  may  enter  into  the  com- 
position of  the  sputa  of  consumptive  subjects,  viz.  catarrhal 
mucus, — the  matter  of  tubercles  more  or  less  softened, — and 
(sometimes)  the  pus  secreted  by  tuberculous  excavations  which 
are  completely  empty.  Neither  chemical  analysis  nor  the  physical 
characters  of  these  matters,  enables  us  certainly  to  discriminate 
them  from  each  other.f     In  general,  no  doubt,  pus  is  more  opaque, 

behind  the  sternum.  In  fine,  Laennec  is  quite  correct  in  saying  that  many 
phthisical  persons  have  no  pain  whatever  in  the  chest  during  the  whole  course 
of  their  malady ;  and  this  is  one  of  the  circumstances  by  which  a  great  number 
of  patients  are  kept  in  a  state  of  perfect  confidence  as  to  their  health.  The 
lesion  of  the  lungs  not  only  develops  itself,  arrives  at  ulceration  and  brings 
round  it  acute  or  chronic  inflammation  without  pain,  but  in  the  same  individuals 
also,  many  other  parts  alter,  inflame,  and  become  disorganized  without  giving  any 
warning  by  pain.  Thus  many  phthisical  subjects,  under  a  total  loss  of  the 
voice  and  with  the  larynx  full  of  ulcerations,  do  not  complain  up  to  the  moment 
of  their  death,  of  any  painful  sensations  in  this  organ.  In  the  case  of  most  of 
them,  the  mucous  membrane  of  the  stomach  is  also  softened,  the  intestines  are 
filled  with  tubercles,  and  numerous  large  ulcerations  form  on  their  inner  surface 
without  causing  pain.  In  others  the  peritoneum  is  raised  by  myriads  of  tuber- 
cles, and  false  membranes  cover  it,  yet  no  pain  is  occasioned.  Finally,  in  cases 
where  tubercles  invade  simultaneously  a  great  number  of  organs,  no  one  of 
them  in  general  betrays  its  morbid  condition  by  pain.  Yet  there  are  deplorable 
exceptions  to  these  cases.  Some  phthisical  subjects  are  afflicted  with  excessive 
pain  in  the  abdomen  from  the  moment  of  the  occurrence  of  diarrhoea;  others 
have  equally  tormenting  pains  in  the  larynx,  and  some  cannot  swallow  without 
the  most  acute  suffering  :  this  happens  particularly  when  the  epiglottis  and  the 
parts  which  form  the  superior  opening  of  the  larynx  are  specially  altered. — 
Andral. 

*  31.  Louis  furnishes  strong  reasons  for  believing  that  the  pains  in  cases  of 
phthisis  are  almost  always  owing  to  the  slight  chronic  pleurisies  which  occasion 
the  cellular  adhesions  found  after  death.  These  adhesions,  it  is  well  known, 
generally  coincide  with  the  presence  of  tubercles  or  tuberculous  excavations  in 
the  lungs :  but  that  the  pains  are  owing  to  the  pleurisy  and  not  the  tubercles, 
seems  probable  from  the  following  considerations: — 1.  tubercles  exist  in  other 
parts,  as  the  glands,  without  pain  ;  2.  the  pain  in  cases  of  phthisis  resembles 
that  of  pleurisy,  in  being  affected  by  respiration,  &c.  &c;  3.  in  some  cases 
where  large  excavations  existed  on  one  side  with  little  or  no  adhesions,  and 
numerous  adhesions,  on  the  other  with  few  or  no  excavations,  the  pain  had  been 
principally  in  the  latter  side;  4.  in  the  cases  (twenty-two  in  number)  in  which 
no  pain  had  existed,  adhesions  were  found  only  at  the  summit  of  the  lungs,  a  sit- 
uation in  which  pleuritic  pains  would  be  naturally  less,  owing  to  the  comparative 
immobility  of  that  part  ot  the  chest.  31.  Louis,  however,  admits,  that  in  some 
cases  pain  had  existed  when  no  trace  of  pleurisy  could  be  detected  after  death. 
Recherchcs,  p.  205. —  Transl. 

t  Although  we  could  distinguish  pus  from  mucus  by  sure  chemical  characters, 


316  PHTHISIS    PULMONALIS. 

more  intimately  blended,  and  more  fetid  than  catarrhal  mucus ; 
yet  nothing  is  more  common  than  to  observe  in  simple  chronic 
catarrhs,  sputa  of  a  character  entirely  puriform.  It  is  extremely 
rare  to  meet  with  well-marked  tuberculous  matter  in  the  expec- 
toration. When  this  is  completely  softened,  it  combines  so  in- 
timately with  the  puriform  mucus  secreted  by  the  bronchi,  that 
it  is  impossible  to  distinguish  the  one  from  the  other.  Besides, 
tuberculous  matter  can  only  form  a  very  small  proportion  of  the 
expectoration  when  this  is  at  all  considerable.  If  it  amounts  to 
more  than  a  pound  daily,  considering  how  slowly  the  excavations 
empty  themselves,  we  cannot  believe  that  the  tuberculous  matter 
can  amount  to  more  than  twelve  grains — that  is,  to  a  thousandth 
part  of  the  whole.  Sometimes,  indeed,  but  very  rarely,  we 
observe  in  the  expectoration,  small  fragments  of  softened  tuber- 
culous matter,  very  distinct.  In  one  case  already  recorded, 
I  witnessed  the  expectoration  of  a  pretty  large  fragment  of 
tuberculous  matter  with  a  portion  of  lung  attached  to  it. 
But  we  may  be  very  easily  deceived  in  respect  to  this  kind  of 
expectoration.  The  mucous  follicles  of  the  tonsils  frequently 
secrete  a  fatty  matter,  of  a  slightly  yellowish  white  color,  half- 
concrete  and  friable,  and  extremely  like  tuberculous  matter  in 
appearance.  It  differs  from  this,  however,  in  two  striking  char- 
acters :  it  emits  a  fetid  odor  when  squeezed,  and  it  greases  paper 
when  heated  on  it.  This  kind  of  secretion  is  often  very  great  in 
persons  in  good  health.  I  was  once  deceived  myself  by  a  case  of 
this  kind.  A  patient  came  into  the  hospital  in  a  state  of  ex- 
treme emaciation,  and  with  considerable  expectoration.  On  ex- 
amining his  spitting-pot,  I  observed  the  muco-puriform  sputa 
intermixed  with  numerous  fragments  of  a  matter  resembling  that 
of  tubercles,  and  some  larger  than  cherry-stones.  I  looked  upon 
the  patient  as  phthisical;  but  he  died  on  the  following  night, 
before  I  had  an  opportunity  of  exploring  the  chest,  and  of  a  dis- 
ease quite  unconnected  with  this  cavity.  Upon  examining  the 
body,  the  lungs  were  found  quite  sound,  and  the  follicles  of  the 
tonsils  filled  and  dilated  with  a  fatty  matter  similar  to  that  ex- 
pectorated by  the  individual.  Generally  speaking,  then,  the 
expectoration  in  phthisis  is  similar  to  that  of  chronic  catarrh — 
being  mucous,  opaque,  little  soluble  in  water,  containing  a  few 
air-bubbles,  of  a  pale  yellow,  or  yellowish  white,  and  sometimes 
of  a  slightly  greenish  or  ash  color.  These  characters  vary  some- 
what with  the  period  of  the  disease.     In  the  beginning,  the  yel- 

yet  this  would  not  help  the  inquiry  whether  the  liquids  under  analysis  proceeded 
from  an  excavation  in  the  parenchyma  of  the  lungs  or  from  the  mucous  mem- 
brane of  the  bronchi.  In  fact,  it  is  now  well  known  that  the  different  mucous 
membranes  under  inflammation  may  secrete  a  matter  exactly  resembling  pus. 
Andral. 


SYMPTOMS    AND    PROGRESS. 


377 


low  and  formed  sputa  are  intermixed,  as  in  many  cases  of  acute 
catarrh,  with  a  colorless  and  diffluent  watery  phlegm,  with 
which  they  do  not  combine  on  account  of  their  comparative  in- 
solubility. Later  in  the  disease,  the  watery  or  pituitous  expec- 
toration ceases,  and  the  concocted  or  formed  sputa  unite  in  one 
mass.  Towards  the  close  of  the  disease,  the  expectoration  be- 
comes usually  less  and  less  copious,  and  assumes  an  ash  or  dirty 
green  color.  At  this  time,  its  diminished  cohesion,  its  complete 
opacity,  and  its  greater  solubility  in  water,  lead  to  the  opinion 
that  it  contains  a  certain  proportion  of  black  pulmonary  matter 
and  pus,  secreted  by  the  walls  of  excavations  nearly  empty.  In 
every  stage  of  the  disease,  we  sometimes  observe  in  the  expecto- 
ration, cylindrical  and  vermicular  portions  which  appear  moulded 
in  the  smaller  bronchi.  To  conclude, — we  cannot  yield  much 
confidence  to  the  inspection  of  the  sputa  in  this  disease,  inasmuch 
as  those  which  are  most  characteristic, — viz.  the  ash-colored, 
puriform  and  vermicular, — are  frequently  met  with  in  chronic 
catarrh  ;  and  because  it  appears,  from  what  was  formerly  stated, 
that,  with  the  exception  of  about  a  thousandth  part,  the  whole 
of  the  expectoration  is  the  product  of  the  pulmonary  catarrh, 
with  which  the  tuberculous  affection  is  almost  always  compli- 
cated. The  progress  of  this  catarrh  is  very  various.  Sometimes 
the  yellow  mucous  expectoration  commences  with  the  first  obvious 
symptoms  of  the  disease ;  sometimes  it  succeeds  these ;  most  com- 
monly it  appears  to  begin  at  the  period  of  the  softening  of  the 
first  crop  of  tubercles ;  and,  lastly,  in  some  rare  cases,  it  shows 
itself  only  when  the  tuberculous  matter  first  makes  its  way  into 
the  bronchi*  It  is,  indeed,  to  the  re-union  of  these  two  circum- 
stances, viz.  the  evacuation  of  a  large  tuberculous  excavation, 
and  the  simultaneous  development  of  a  very  extensive  and  very 
loose  catarrh,  that  we  must  attribute  the  greater  number  of  those 
cases  known  to  practitioners  by  the  name  of  vomica, — respecting 
which  I  shall  here  make  a  few  remarks,  premising  merely  that  it 
is  much  less  frequent  than  it  is  supposed  to  be.f 

*  It  is  not  only  true  as  Laennec  thinks,  and  as  I  have  clearly  shown  in  my 
Clinique  Medicalc,  that  the  sputa  of  phthisical  patients  often  cannot  be  distin- 
guished from  those  arising  from  a  simple  chronic  bronchitis,  but  it  must  not  be 
forgotten  that  sometimes  pulmonary  phthisis  passes  through  all  its  stages  and 
comes  to  a  fatal  termination,  without  any  expectoration  at  all :  the  cough  is  dry 
to  the  last,  or  at  most  is  attended  by  a  discharge  from  time  to  time,  of  a  trans- 
parent, colorless,  mucous  matter,  similar  to  that  expectorated  in  the  beginning  of 
the  most  simple  acute  bronchitis.  Cases  of  this  sort  may  be  found  in  my  Clin- 
ique Medicalc.  The  expectoration  also  is  often  in  a  manner  intermittent,  and  it 
is  only  at  intervals  that  a  puriform  matter  is  mingled  with  the  expectoration, 
and  assists  the  diagnosis. — Andral. 

t  I  do  not  think  that  our  author  has  done  sufficient  justice  to  the  expectora- 
tion, as  a  sign  of  the  presence  of  tubercles  in  the  lungs;  more  especially  in  the 
latter  stages  of  the  disease.  It  is  no  doubt  true,  that  every  one  of  the  characters 
-of  phthisical  sputa  may  be  sometimes  met  with  in  those  of  chronic  catarrh  or 

4P 


378  PHTHISIS    PULMONALIS. 

Vomica  of  the  lungs. — By  this  term  is  commonly  understood 
a  sudden  and  copious  expectoration  of  puriform  matter,  coming 
on  after  symptoms  of  incipient  phthisis.  In  cases  of  this  kind, 
after  an  expectoration  so  abundant  as  almost  to  suffice  to  fill  one 
of  the  sides  of  the  chest  in  twenty-four  hours,  we  sometimes  find 
the  cough  and  expectoration  gradually  lessen  for  a  few  days, 
and  see  the  patient  restored  to  a  state  of  perfect  and  permanent 
health.  More  commonly,  however,  after  a  temporary  amelio- 
ration, the  disease  resumes  its  march,  becomes  even  more  distinct 
than  before,  and  soon  puts  an  end  to  the  patient's  life.  Cases  of 
the  kind   just    mentioned,  had  early  engaged  the  attention    of 

bronchitis;  but  I  believe  this  to  be  by  no  means  a  common  case;  and  I  think 
that  we  hardly  ever  meet  with  an  instance  of  the  latter  disease  in  which  the 
expectoration  undergoes  the  progressive  changes  so  frequently  observed  in 
phthisis.  For  the  fullest  and  most  accurate  account  we  possess  of  the  expectora- 
tion in  this  disease,  I  refer  the  reader  to  Andral's  work,  torn.  iii.  p.  118;  and  for 
a  correct  but  briefer  detail,  to  that  of  Louis,  p.  187.  The  expectoration  in  phthisis 
has  engaged  the  attention  of  medical  writers  more  than  that  of  any  other  dis- 
ease of  the  lungs  ;  and  many  valuable  observations  respecting  it  are  to  be  found 
in  the  writings  of  the  ancients,  particularly  Hippocrates  and  Aretceus :  and  also 
in  the  works  of  the  early  moderns,  among  which  those  of  our  countrymen,  Ben- 
net  and  Morton,  deserve  particular  notice.  (Theatrum  Tabidorum. — Phthisiolo- 
gia.)  It  maybe  of  some  use  to  the  student,  if  I  state  here,  in  a  few  words,  what 
appear  to  me  the  most  usual  characters  and  progressive  changes  of  the  expectora- 
tion in  phthisis. — In  the  earliest  stage  of  the  disease,  the  cough  is  cither  quite 
dry,  or  attended  by  a  mere  watery  or  slightly  viscid,  frothy,  and  colorless  fluid ; 
this,  on  the  approach  of  the  second  stage  gradually  changes  into  an  opaque, 
greenish,  thicker  fluid,  intermixed  with  small  lines  or  fine  streaks  of  a  yellow 
color.  At  this  period  also,  the  sputa  are  sometimes  intermixed  with  small 
specks  of  a  dead  white  or  slightly  yellow  color,  varying  from  the  size  of  a  pin's 
head  to  that  of  a  grain  of  rice,  and  which  have  been  compared  by  Bayle  to 
this  grain  when  boiled.  These  have  been  noticed  by  many  writers  from  Hippoc- 
rates downwards.  After  the  complete  evacuation  of  the  tubercles,  the  expecto- 
ration puts  on  various  forms  of  purulcncy  :  but  frequently  assumes  one  particular 
character,  which  has  always  appeared  to  me  pathognomonic  of  phthisis,  although 
the  more  accurate  and  extensive  observation  of  modern  pathologists  has  proved 
the  same  to  exist  occasionally  in  simple  catarrh.  The  expectoration  to  which  I 
allude  consists  of  a  series  of  globular  masses,  of  a  whitish-yellow  color,  with  a 
rugged  woolly  surface,  and  somewhat  like  little  rolled  balls  of  cotton  or  wool. 
These  commonly  but  not  always  sink  in  water.  This  kind  of  expectoration 
has  appeared  to  me  most  common  in  young  subjects,  of  a  strongly  marked  stru- 
mous habit,  and  in  whom  the  disease  was  hereditary.  At  other  times,  in  the 
cases  in  which  these  globular  masses  are  observed,  and  also  in  those  in  which 
they  have  not  appeared,  the  expectoration  puts  on  the  common  characters  of  the 
pus  of  an  abscess,  constituting  an  uniform,  smooth,  coherent,  or  diffluent  mass, 
of  a  greenish,  or  rather  greyish  hue,  with  an  occasional  tinge  of  red,  (from  inter- 
mixed blood,)  and  sometimes  more  or  less  fetid.  This  is  the  "  sputum  cinereum 
et  caenosum,  argillae  cujusdam  liquidioris  speciem  prae  se  ferens"  of  Bennet.  It 
is  unnecessary  to  take  any  notice,  in  this  place,  of  the  point  once  so  much  dis- 
cussed and  deemed  so  important,  of  the  difference  between  pus  and  mucus,  and 
of  the  chemical  tests  of  each ;  since  it  has  been  long  ascertained  that  a  mucous 
membrane  in  a  state  of  inflammation,  is  as  capable  of  secreting  true  pus,  as  an 
ulcerated  surface.  The  alleged  sweetness  or  saltness  of  the  expectoration,  has 
also,  I  believe,  been  long  discarded  by  pathologists  as  a  test  of  the  existence  of 
tubercular  diseases  of  the  lungs,  although  we  certainly  much  more  frequently 
hear  our  phthisical  purients  notice  these  qualities  of  the  expectoration,  than  per- 
sons affected  with  other  diseases  of  the  chest.—  Transl. 


SYMPTOMS    AND    PROGRESS. 


379 


physicians.  Hippocrates  has  treated  largely  of  them  in  several 
parts  of  his  writings.  He  considered  vomicae  as  true  abscesses 
of  the  lungs,  and  denominated  the  patients  to  whom  they  oc- 
curred, empyical  or  suppurated  (f>™°<).  This  name  indeed  he 
applies  to  all  those  who  have  an  abscess,  in  whatever  part  of  the 
body  it  may  be ;  but  in  modern  times  the  term  has  been  re- 
stricted to  collections  of  matter  in  the  pleura.  Vomicae  of  the 
lungs  were  considered  by  Hippocrates  as  differing  from  phthisis. 
He  says  they  may  open  either  into  the  bronchi  or  the  cavity  of 
the  pleura.  The  former  of  these  terminations  appeared  to  him 
fortunate,  and  he  sometimes  even  endeavored  to  produce  it 
artificially,  by  forcibly  shaking  the  patient's  trunk*  The  latter 
was  reckoned  the  usual  cause  of  the  pleuritic  empyema. 

These  notions,  although  very  inaccurate  in  several  respects 
are  still  entertained  by  many  physicians  who  are  ignorant  of  the 
present  state  of  pathological  anatomy.  In  one  very  important 
point,  that  of  the  origin  of  the  affection,  these  views  of  Hip- 
pocrates are  erroneous ;  since,  as  has  already  been  shown,  the 
formation  of  an  abscess  in  the  lungs,  the  consequence  of  inflam- 
mation, is  an  extremely  rare  case, — at  least  a  hundred  times 
as  rare  as  a  well-marked  vomica,  and  a  thousand  times  as 
rare  as  an  empyema.  I  consider  vomicae,  such  as  I  have  de- 
scribed, and  such  as  are  so  named  by  practitioners,  as  the  result 
of  the  softening  of  a  tuberculous  mass  of  a  large  size.  It  is  to 
be  remarked,  however,  that  the  copious  expectoration  which 
usually  takes  place  during  several  days  after  their  rupture,  can- 
not be  considered  as  the  sole  product  of  the  tuberculous  matter. 
In  a  case  formerly  under  my  care,  the  patient,  after  having,  for 
several  months,  been   subject  to  dry   cough,  dyspnoea,!  hectic 

*  That  Hippocrates  was  well  acquainted  with  Succussion  as  a  means  of  diag- 
nosis in  thoracic  diseases,  is  evident  from  many  passages  in  his  writings;  and 
he  is  even  entitled  to  the  merit  of  having  practised  auscultation  (though  with- 
out any  useful  result)  by  the  application  of  the  ear  to  the  chest,  as  is  indeed 
noticed  by  M.  Laennec  in  the  beginning  of  the  present  work.  Not  contented 
with  this,  Dr.  Baron  in  his  •■  Illustrations,"  contends  that  he  was  acquainted 
also  with  Percussion.  This  I  conceive  to  be  an  opinion  not  at  all  supported  by 
a  candid  examination  of  the  writings  of  Hippocrates.— Trafid. 

\  In  the  enumeration  of  the  symptoms  of  pulmonary  phthisis,  Laennec  has 
not  mentioned  dyspnoea.  It  is  indeed  slight  in  a  great  many  cases,  and  if  not 
so  in  some  exceptional  cases  which  I  shall  proceed  to  describe,  it  is  never  com- 
parable to  that  caused  by  emphysema  of  the  lungs,  somewhat  extended,  or  by 
an  organic  affection  of  the  heart.  Yet  this  dyspnoea  is  worthy  of  some  obser- 
vations. There  are  cases,  and  they  arc  not  uncommon,  where  long  before  any 
other  symptom  gives  rise  to  suspicion  of  phthisis,  an  oppression  in  the  breathing 
is  already  very  manifest :  many  persons  who  had  evident  marks  of  tubercles  in 
the  lungs  at  the  time  I  examined  them,  have  assured  me  that  from  early  infancy 
tlnir  respiration  was  habitually  short,  and  that  they  had  not  been  able  to  run, 
walk  fast,  or  read  aloud,  without  a  certain  degree  of  oppression.  I  have  known 
in  the  same  families,  several  individuals  who  became  phthisical  one  after  the 
other,  and  who  bejran  to  suffer  from  shortness  of  breathing  :  they  regarded  this 
dyspncea  as   a    habit  of  the  family,  and  gave  themselves   no  concern  about  it ; 


380  PHTHISIS    PULMONALE. 

fever,  and  other  symptoms  indicative  of  tubercles,  after  a  violent 
fit  of  coughing  suddenly  expectorated  nearly  a  glassful  of  puri- 
form  matter,  which  was  opaque  and  almost  diffluent.  For  eight 
days  afterwards,  he  brought  up  about  three  pints  of  a  similar 
fluid  every  twenty-four  hours.  The  expectoration  then  grad- 
ually subsided,  and  at  last  ceased  entirely,  together  with  the 
symptoms  which  had  preceded  it ;  and  the  patient  left  the  hos- 
pital, at  the  end  of  a  month,  perfectly  cured.  A  discharge  so 
copious  as  this  can  only  be  accounted  for  by  secretion  ;  and  in 
the  case  in  question,  there  is  no  doubt  that  the  sources  of  the  ex- 
pectoration were  the  walls  of  a  large  tuberculous  excavation,  and 
the  bronchial  membrane  irritated  by  the  discharge  of  the  contents 
of  this. 

It  is  to  be  remarked  in  this  place,  that  the  case  known  in  prac- 
tice by  the  term  vomica,  and  which  is  justly  considered  as  uncom- 
mon, differs  in  nothing  but  degree  from  a  case  which  is  very  com- 
mon, and  which  may  be  frequently  observed  in  an  hospital,  by 
any  one  who  carefully  attends  to  the  expectoration  of  a  great 
number  of  phthisical  patients.  Some  other  affections  have  been 
frequenrly  confounded,  under  the  name  of  vomica,  with  that  just 
described  ;  and  particularly  abscess  of  the  lungs,  abscess  of  the 
liver  opened  through  the  diaphragm  into  the  chest,  and  the  effu- 
sions of  pleurisy  which  have  found  their  way  into  the  bronchi.* 

The  general  symptoms  above  described,  which  accompany 
manifest  phthisis,  cannot  be  considered,  even  when  re-united  in 
the  same  case,  as  certain  signs  of  the  existence  of  tubercles  in  the 
lungs.  A  simple  catarrh  may  give  rise  to  the  same  effects. 
Twenty  years  ago  I  witnessed  the  death  of  a  young  woman,  pre- 
ceded by  all  the  symptoms  of  phthisis  pulmonalis,  whose  lungs 
were  found,  on  examination,  perfectly  sound,  and  in   whom  no 

they  would  not  have  mentioned  it  to  me  had  I  not  drawn  their  attention  to  it. 
In  general  as  pulmonary  phthisis  advances,  the  difficulty  of  breathing  increases, 
and  commonly  becomes  considerable  in  the  last  stages  of  life.  There  are  be- 
sides, many  phthisical  subjects  in  whom,  during  the  whole  course  of  the  disease, 
the  predominant  svmptom  is  a  dyspnoea  of  such  a  degree  that  it  is  suspected  to 
proceed  from  an  affection  of  the  heart,  yet  auscultation  shows  nothing  irregular 
in  that  organ.  These  are  not  the  cases  in  which  vast  cavities,  or  tuberculous 
masses,  are  found  accumulated  towards  the  top  of  the  lungs.  But  it  is  com- 
mon in  such  cases  to  find  the  lungs  studded  with  miliary  tubercles  which  seem 
every  where  to  obstruct  the  entrance  of  air  into  the  vesicles. — Andral. 

*  A  gangrene  of  the  lung  may  also  cause  a  sudden  expectoration  of  a  great 
quantity  of  purulent  matter;  and  there  are  singular  cases  in  which  the  mucous 
membrane  of  the  bronchi  gives  out,  all  at  once,  a  very  abundant  secretion  of 
puriform  liquid  which  being  rapidly  expectorated,  may  cause  the  belief  of  the 
existence  of  a  purulent  collection  slowly  formed  in  the  lung,  and  afterwards 
evacuated  in  a  mass  through  the  bronchi.  In  my  Cliniquc  Mcdicale  are  6ome 
observations  of  this  sort;  no  accidental  cavity  existed  in  the  lung,  the  pleura 
was  sound,  yet  the  bronchi  contained  even  in  their  minutest  ramifications,  a 
purulent  liquid  similar  to  that  which  by  a  rapid  and  continued  discharge  during 
life  bore  the  appearance  of  a  vomica.—  AndrnL 


SYMPTOMS    AND    PROGRESS.  381 

organic  lesion  was  discoverable,  except  in  the  liver.  Bayle  gives 
two  examples  of  the  same  kind,  (Cases  xlviii.  and  xlix.)  On 
this  account,  we  ought  never  to  assert  positively  the  existence  of 
phthisis  pulmonalis,  in  cases  where  none  of  the  physical  signs 
afforded  by  percussion  and  auscultation,  are  found  to  exist.  In 
the  course  of  the  last  year,  I  several  times  met  MM.  Recamier 
and  Richerand  in  consultation,  on  the  case  of  a  young  lady  who 
seemed  already  far  gone  in  a  consumption,  but  in  whom  I  con- 
stantly affirmed  the  lungs  to  be  sound,  from  the  absence  of  physi- 
cal signs  in  this  case.  The  result  of  the  dissection  confirmed  the 
correctness  of  my  diagnosis  :  the  disease  was  schirrous  pancreas, 
complicated  with  a  simple  catarrh.* 

2.  Irregular  manifest  phthisis. — I  wish  to  designate  by  this 
term,  those  cases  of  phthisis,  in  which  the  disease  seems  to  begin 
in  some  other  organ  besides  the  lungs.  It  is  by  no  means  un- 
common to  find  the  local  and  general  symptoms  of  consumption, 
preceded  by  a  chronic  diarrhoea  of  long  standing.  On  examining 
the  bodies  of  such  persons  after  death,  we  find  a  great  many 
ulcers  in  the  intestines,  and  in  most  of  these,  small  miliary  tuber- 
cles, or  tubercles  already  softened  and  destroyed.  When  in  such 
cases  perforation  of  the  intestinal  tunics  takes  place,  an  acute 
peritonitis,  accompanied  by  peritoneal  tympany,  commonly  super- 
venes suddenly.  This  double  affection  is  indicated  by  the  fol- 
lowing signs :  viz.  sudden,  acute,  and  sometimes  most  extreme 
pain  of  the  belly,  great  alteration  of  the  features,  and  complete 
prostration  of  strength.  The  pain  is  increased  by  pressure,  but 
usually  less  so  than  in  most  cases  of  acute  peritonitis.  In  gently 
compressing  the  abdomen,  or  in  pressing  with  a  single  finger  the 
parts  of  it  which  are  most  swollen,  we  are  sensible  of  a  sort  of 
dry  crepitation  ;  and  in  percussing  the  part  gently,  while  at  the 
same  time  we  apply  the  stethoscope  near  it,  we  hear  a  silvery  sort 
of  resonance,  more  clear  than  in  .common  intestinal  tympany.  If 
the  adhesion  of  the  ulcer  to  the  parts  surrounding  it,  takes  place 
immediately,  these  signs  in  general,  do  not  exist  at  all.  Perfo- 
ration of  the  intestines  from  tuberculous  ulcers  may  also  take 
place,  though  more  rarely,  in  examples  of  regular  phthisis,  and 
when  the  intestinal  affection  shows  itself  only  at  an  advanced 
period  of  the  disease.f     The  examples  of  consumption  which  are 

*  In  my  Climque  Medicate,  3d  edit.  I  have  cited  the  case  of  a  young  girl  who 
had  all  the  rational  symptoms  of  pulmonary  phthisis:  she  was  subject  to  the 
sweats  which  mark  a  certain  period  of  this  affection  ;  auscultation  and  percus- 
sion gave,  it  is  true,  only  negative  signs.  The  lungs  were  found  sound;  the 
only  lesion  that  existed,  and  to  which  must  be  referred  the  symptoms  apparent 
during  life,  was  an  abscess  of  the  spleen,  an  affection  very  rare,  and  of  which 
only  a  few  well  authenticated  examples  are  known. — Andral. 

t  For  the  best  account  we  possess  of  perforation  of  the  intestines,  see  the  arti- 
cles Enteritis,  Peritonitis,  and  Perforation,  in  the  Cyclopaedia  of  Pract.  Med. — 
Transl. 


382  PHTHISIS    PULM0NALIS. 

preceded  by  a  prolonged  diarrhoea,*  are  usually  attended  by  a 
greater  emaciation  and  prostration  of  strength  than  in  common 
cases  ;  in  them  the  skin  is  also  harsh,  and  has  none  of  that  fine- 
ness, and  thatpalid  white  and  waxen  hue,  which  exist  in  the  great- 
er number  of  common  consumptive  subjects.  In  these  cases  also, 
death  soon  follows  the  establishment  of  the  expectoration  and 
other  local  pectoral  symptoms;  although,  indeed,  by  means  of 
the  stethoscope,  the  existence  of  tubercles  already  softened  or 
even  excavated,  might  have  been  previously  ascertained.  In 
scrophulous  subjects,  particularly  children,  the  tuberculous  affec- 
tion begins,  pretty  frequently,  in  the  mesenteric  or  cervical  glands, 
the  tubercles  in  the  lungs  (occasionally  few  in  number)  being 
most  commonly  the  result  of  a  secondary  eruption.  Sometimes 
even,  in  subjects  of  this  kind,  we  meet  only  with  tubercles  in  the 
large  bronchial  glands  at  the  roots  of  the  lungs.  When  tubercu- 
lous phthisis  begins  in  the  messenteric  glands,  death  frequently 

*  For  the  most  valuable  illustrations  respecting  the  nature  and  degree  of  preva- 
lence of  diarrhoea  in  phthisis  which  we  possess.  I  must  still  refer  the  reader  to 
the  works  of  Andral  and  Louis.  I  shall  here  abridge  some  of  the  observations 
of  these  authors,  particularly  the  latter.  Out  of  one  hundred  and  twelve  case3 
of  phthisis,  diarrhoea  was  wanting  in  five  only.  In  some,  it  preceded  any  sign 
of  phthisis  pulmonalis  ;  in  about  one-eighth,  it  began  at  the  same  time  as  the 
disease  of  the  lungs,  and  attended  its  whole  course,  from  five  to  twelve  months, 
and  even,  in  some  cases,  during  the  greater  part  of  four  or  five  years  ;  in  the 
majority  of  cases,  it  began  in  the  latter  half  of  the  existence  of  phthisis  ;  and  in 
one-fourth,  it  appeared  only  between  the  fiftieth  and  twentieth  day  preceding 
death.  In  these  cases,  which  may  be  called  the  diarrhoea  of  the  latter  days,  the 
intestines  were  found  diseased  in  every  case  but  one  :  in  one-half,  there  was  ul- 
ceration of  the  mucous  membrane  either  of  the  small  or  large  intestines,  or  both, 
and  in  every  case  but  three,  the  ulcers  were  small  and  rare  ;  in  four-fifths  of  the 
cases,  the  mucous  membrane  of  the  colon  was  reduced  to  a  soft  pulp,  and 
was  almost  always  more  or  less  red.  The  diarrhoea  was  proportioned  to  the  ex- 
tent of  the  organic  lesion,  and  was  greater  when  the  membrane  was  softened, 
than  when  it  was  simply  ulcerated.  The  diarrhcea  of  long  standing  Was  either 
remittent  or  continued.  In  the  former  kind,  which  was  observed  in  fifteen  cases, 
the  lesions  were  the  same  as  in  the  variety  just  described,  being  comparatively 
slight.  The  diarrhoea  continued  from  forty-eight  days  to  five  months,  and  the 
remissions  lasted  eight,  ten,  fifteen,  or  twenty  days.  The  continued  diarrhoea  if 
long  standing,  lasted  from  one  to  twelve  months.  Out  of  forty-one  cases,  the 
small  intestines  were  ulcerated  in  thirty-five,  the  large  in  thirty-one  ;  in  twelve 
cases,  the  small  intestines  were  ulcerated  through  their  whole  course,  and  in 
thirteen,  the  ulcers  were  as  large  as  an  ineh  in  diameter;  in  nineteen  cases  there 
were  large  ulcerations  in  the  great  intestines;  in  thirty,  the  mucous  membrane 
of  these  was  of  a  pulpy  softness,  and  in  seventeen  it  was  red.  As  a  general 
rule,  it  was  found,  that  when  the  diarrhoea  had  been  of  long  standing  and  con- 
tinued, the  ulcers  were  large  and  numerous.  The  diarrhoea  was  found  to  be  as 
severe  when  the  ulcers  were  in  the  small,  as  when  they  were  in  the  large  intes- 
tines ;  but  the  much  greater  frequency  of  softening  of  the  membrane  of  the 
latter,  (which  appears  to  be  the  consequence  of  inflammation,)  proves  that  the 
site  of  this  symptom  is  much  more  commonly  in  the  large  than  the  small  intes- 
tines. In  every  case  where  there  was  much  ulceration,  the  diarrhoea  was  not 
only  of  long  duration  and  continued,  but  the  stools  were  also  frequent  ;  and  the 
loss  of  strength,  and  the  emaciation,  were  always  proportioned  to  the  number 
and  frequency  of  the  stools.  There  appears  to  be  no  just  foundation  for  the 
common  opinion,  of  diarrhcea  alternating  with  the  sweating  in  phthisis,  or  the 
one  being  supplementary  to  the  other.—  Transl. 


SYMPTOMS    AND    PROGRESS. 


383 


supervenes  from  defective  nutrition,  before  any  symptom  of  pul- 
monary consumption  shows  itself.  In  examining  the  bodies  of 
such  subjects,  however,  we  almost  always  meet  with  some  miliary 
tubercles  in  the  lungs. 

3.  Latent  phthisis. — It  very  seldom  happens  that  phthisis  is 
latent  through  its  whole  course ;  but  it  is  by  no  means  rare  to 
meet  with  cases  in  which  the  characteristic  symptoms  show  them- 
selves only  a  few  weeks,  or  even  days,  before  death ;  and  which 
had  been  previously  mistaken  for  diseases  of  quite  a  different 
nature.  Cases  of  this  kind  occur  most  commonly  during  the 
course  of  another  chronic  disease,  capable  by  itself  of  occasioning 
emaciation  and  slow  fever,  such  as  scurvy,  inveterate  syphilis,  &c. 
These  scorbutic,  venereal,  or  murcurial  consumptions,  as  they  are 
usually  called,  have  nothing  peculiar,  except  in  being  developed 
during  the  presence  of  the  affections  mentioned ;  and  to  which, 
in  fact,  there  is  no  proof  of  their  being  owing.  Some  cases  of 
phthisis,  beginning  with  diarrhoea,  prove  fatal,  without  being  ever 
attended  by  cough  or  expectoration,  as  was  formerly  observed 
by  M.  Portal ;  but  in  such  instances,  crude  tubercles  are  usually 
found  in  the  lungs.  Phthisis  may  be  long  masked  by  nervous 
symptoms.  1  have  known  several  cases  in  which  it  was  concealed 
for  years  by  an  habitual  dyspepsia,  and  other  symptoms  of  hypo- 
chondriasis. One  of  these,  a  confirmed  hypochondriac  of  ten  years, 
and  who  still  preserved  his  strength  and  plumpness,  was  suddenly 
attacked  with  an  acute  catarrh,  which  was  succeeded,  after  five 
days,  by  an  expectoration  of  puriform  mucus,  mixed  with  a  little 
blood.  These  symptoms  subsided  in  the  course  of  a  few  days  ; 
but  after  six  months  they  were  succeeded  by  symptoms  of  a  de- 
cided phthisis,  which  carried  the  patient  off  within  six  weeks.* 
Of  all  the  affections  of  the  lungs,  the  pulmonary  catarrh  is  the 
most  apt  to  mask  phthisis ;  since,  on  the  one  hand,  it  may  itself 
be  accompanied  by  haemoptysis,!  hectic  fever,  considerable  ema- 
ciation, and  an  expectoration  which  it  is  impossible  to  distinguish 
from  that  of  phthisis ;  and,  on  the  other,  the  symptomatic  catarrh 

*  I  have  sometimes  seen  pulmonary  phthisis  supervene  in  the  course  of 
chlorosis,  and  in  consequence  of  this,  the  symptoms  remained  for  a  long  time 
so  obscure  as  to  leave  some  doubt  of  the  existence  of  the  pulmonary  disorder. 
In  fact,  it  would  be  quite  natural  to  ascribe  the  dyspnoea  and  the  constantly  aug- 
menting weakness  to  chlorosis  :  yet  the  continuance  of  the  cough,  the  haemop- 
tysis and  fever,  at  length  cause  suspicion,  and  auscultation  reveals  the  truth. 
We  should  then  examine  attentively  the  chests  of  chlorotic  patients,  and  re- 
member that  the  debility  which  accompanies  chlorosis,  and  which  is  one  of  its 
elements,  predisposes  the  system  in  a  remarkable  manner  to  the  formation  of  a 
tuberculous  diathesis. — Andral. 

t  It  is  but  rarely  and  by  exception,  that  a  simple  chronic  bronchitis  is  attend- 
ed by  haemoptysis  so  considerable  as  to  attract  attention.  Whenever,  then, 
during  the  course  of  a  pectoral  affection,  respecting  the  nature  of  which  any 
doubt  remains,  a  haemoptysis  occurs,  there  is  strong  presumption  of  the  exist- 
ence of  tubercles. — Andral. 


384  PHTHISIS    PULMONALIS. 

of  phthisis  may  last  several  months,  and  without  emaciation  or  fe- 
ver. In  respect  of  fever,  it  may  be  stated,  that  it  is  in  general  less 
considerable,  the  fewer  the  tubercles,  and  the  more  unconnected 
they  are  with  one  another.  We  may  indeed  say  that  the  greater 
number  of  cases  of  phthisis  are  latent  at  the  beginning,  since  we 
have  seen  that  nothing  is  more  common  than  to  find  numerous 
miliary  tubercles  in  lungs  otherwise  quite  healthy,  and  in  subjects 
who  had  never  shown  any  symptoms  of  consumption.  On  the 
other  hand,  from  considering  the  greater  number  of  phthisical  and 
other  subjects  in  whom  cicatrices  are  found  in  the  summit  of  the 
lungs,  I  think  it  is  more  than  probable  that  hardly  any  person  is 
carried  off  by  a  first  attack  of  phthisis.*  Since  I  was  first  led  to 
adopt  this  opinion,  on  anatomical  grounds,  it  has  frequently  ap- 
peared quite  clear  to  me,  from  carefully  comparing  the  history  of 
my  patients  with  the  appearances  on  dissection,  that  the  greater 
number  of  those  first  attacks  are  mistaken  for  slight  colds,  and 
that  others  are  quite  latent,  being  unaccompanied  with  either 
cough  or  expectoration,  or  indeed  with  any  symptom  sufficient  to 
impress  the  memory  of  the  patients  themselves.  Case  XX.  affords 
an  example  of  this ;  and  probably  in  Cases  XVII.  XVIII.  XIX. 
XXI.  XXII.  XXIII.  the  defect  of  information  respecting  the 
symptoms  that  accompanied  the  formation  of  cicatrices  found 
after  death,  arose  from  those  symptoms  having  been  so  slight,  as 
to  have  escaped  the  memory  if  not  the  notice  of  the  patient.f 

4.  Acute  phthisis. — Under  this  term  are  included  those  cases, 
which,  after  remaining  latent  for  a  longer  or  shorter  period,  at 
length  unfold  themselves  all  at  once,  with  acute  fever,  emaciation 
and  other  symptoms  of  such  severity  as  to  carry  off  the  patient  at 
the  end  of  six  weeks,  a  month,  or  even  sometimes  within  a  shorter 
period.  In  examining  the  lungs,  in  cases  of  this  kind,  we  com- 
monly meet  with  a  great  number  of  tuberculous  masses,  or  sepa- 
rate tubercles,  which  have  softened  simultaneously,  or  we  find 
secondary  eruptions  of  great  extent,  and  already  considerably  ad- 
vanced in  their  progress.  In  one  remarkable  variety  of  acute 
phthisis,  the  patients  sink  under  the  violence  of  the  fever,  previ- 

*  I  cannot  admit  that  cicatrices  of  cavities  are  found  in  the  lungs  so  often  as 
Laennec  asserts.  Most  persons  accustomed  to  researches  in  pathological  anato- 
my, agree  with  me  on  this  point. — Andral. 

\  Out  of  one  hundred  and  twenty-three  cases  of  phthisis  observed  by  M. 
Louis,  eight  were  latent,  that  is,  exhibited  neither  cough  nor  other  pectoral 
symptoms  during  a  period  varying  from  five  months  to  two  years.  In  four  of 
these  cases,  during  the  period  of  latency,  there  were  neither  local  nor  general 
symptoms  ;  in  the  others  there  was  considerable  general  disturbance,  viz.  fever, 
anorexia,  emaciation,  &c  long  before  the  supervention  of  the  pulmonary  symp- 
toms. Rcchcrches,  p.  368.  For  some  valuable  and  interesting  observations  on 
that  variety  of  latent  phthisis  which  begins  with  diarrhoea,  see  Andral's  work, 
t.  iii-  323.  It  is  noticed  by  Morton,  under  the  head  Tabes  a  dysenteria  et  diar- 
rhoea, Phthisiologia,  p.  38.  Every  practitioner,  as  well  as  myself,  has,  no  doubt, 
met  with  instances  of  this  sort.—  Transl. 


SYMPTOMS    AND    PROGRESS. 


385 


• 


ously  to  emaciation,  and  without  any  other  local  symptoms  but 
those  of  a  very  severe  acute  catarrh.  In  this  case  we  commonly 
find,  on  examining  the  body,  a  great  number  of  crude  yellow  tu- 
bercles, more  or  less  softened,  and  of  considerable  size,  and  al- 
most always  without  any  secondary  eruption.  These  cases  form 
exceptions  to  the  usual  course  of  the  disease  mentioned  above  ; 
the  primary  eruption  of  tubercles  having  been,  in  them,  very  nu- 
merous, and  having  remained  latent  until  the  softening  of  them 
gave  occasion  to  the  symptoms  of  the  violent  pulmonary  catarrh. 
I  met  with  a  remarkable  instance  of  this  kind  about  twenty  years 
ago,  in  the  case  of  a  girl,  eighteen  years  of  age,  who  died  in  the 
Hospital  Cochin,  without  any  emaciation,  or  other  symptom, 
except  those  of  a  severe  feverish  catarrh,  of  less  than  a  month's 
duration.  Upon  examining  the  body,  the  lungs  were  found  filled 
with  tubercles  more  or  less  softened,  of  a  size  almost  uniform, 
and  none  less  than  a  filbert  or  almond.* 

5.  Chronic  phthisis. — Under  this  name  we  may  include  those 
cases  which  last  sometimes  five  or  six  years,  or  even  much  longer, 
marked  by  periods  of  increase,  during  which  the  hectic  fever  is 
manifest,  and  emaciation  makes  rapid  progress ;  and  by  remis- 
sions of  longer  or  shorter  duration,  and  sometimes  so  complete, 
that  the  fever,  cough,  and  expectoration  cease,  and  the  patient 
recovers  his  flesh.  Cases  of  this  kind,  as  must  appear  from  what 
is  stated  above,  are  the  consequences  of  successive  eruptions  of 
tubercles,  usually  also  few  in  number.  It  is  in  these  that  the 
pulmonary  cicatrices  are  most  commonly  found. 

From  all  that  has  gone  before,  it  appears  to  me  useless  to  talk 


*  For  several  interesting  examples  of  acute  phthisis,  I  refer  the  reader  to 
Louis's  work,  p.  411,  and  to  Andral's,  p.  367.  Of  the  general  progress  and 
duration  of  this  disease,  a  more  precise  idea  will  be  afforded  by  the  following 
statement  of  the  results  obtained  by  MM.  Bayle  and  Louis.  Out  of  three  hun- 
dred and  fourteen  cases,  twenty-four  died  within  three  mouths;  sixty-nine  from 
three  to  six  months;  sixty-nine  from  six  to  nine  months;  thirty-two  from  nine 
to  twelve  months ;  forty-three  from  twelve  to  eighteen  months ;  thirty  from 
eighteen  months  to  two  years ;  twelve  from  two  to  three  years;  eleven  from 
three  to  four  years  ;  five  from  four  to  five  years  ;  one  from  five  to  six  years ; 
three  from  six  to  seven  years ;  one  from  seven  to  eight  years ;  three  from  eight 
in  ten  years;  eleven  from  ten  to  forty  years. —  Transl. 

There  is  another  form  of  acute  phthisis,  in  which  the  predominating  symp- 
tom, that  which  most  strikes  the  attention,  and  which  constitutes  the  apparent 
danger,  is  the  dyspnoea:  it  dailv  increases  in  severity,  and  resembles  the  dysp- 
noea depending  on  these  affections  of  the  heart  which  are  most  rapid  in  devel- 
opment: the  patient  sinks  under  a  sort  of  asphyxia,  before  much  emaciation 
has  taken  place,  and  without  exhibiting,  independent  of  dyspnoea,  any  acci- 
dent of  the  respiratory  apparatus,  except  a  cough,  which  often  is  not  remarkable 
cither  for  intensity  or  frequency,  and  is  attended  by  no  particular  expectoration. 
This  is  certainly  one  of  the  cases  in  which  the  true  nature  of  the  disease  may 
be  mistaken.  No  affection  exhibits  similar  characteristics  except  an  emphyse- 
ma of  this  organ,  and  in  this  case  a  very  rapid  development  is  necessary.  My 
Clinique  Medicals  contains  observations  which  will  enable  the  student  to  dis- 
•inguish  this  very  peculiar  and  rare  form  of  acute  phthisis. — Andral. 

49 


386 


PHTHISIS     PULMONALIS. 


of  dividing  consumption  into  two  or  three  degrees — phthisis  in- 
cipiens,  confirmata,  desperata.  This  kind  of  distinction,  being 
founded  on  the  greater  or  less  development  of  the  general  symp- 
toms, has  nothing  fixed  or  constant  ;  since  we  scarcely  ever  find 
these  general  symptoms  proportioned  to  the  state  of  the  expecto- 
ration, or  to  the  extent  of  the  organic  lesions,  in  the  lungs.  Hec- 
tic fever  and  emaciation  frequently  exist  in  a  high  degree  previ- 
ously to  the  appearance  of  the  yellow  and  opaque  sputa,  and 
even  prove  fatal  with  the  single  addition  of  dyspnoea.  At  other 
times,  on  the  contrary,  the  natural  plumpness  of  the  individual, 
and  a  very  tolerable  degree  of  general  health  continue,  for  a  con- 
siderable period  after  the  supervention  of  the  opaque  expectora- 
tion and  pectoriloquism.* 

Sect.  VII. — Treatment  of  phthisis  pulmonalis. 

It  has  been  shown  above,  that  the  cure  of  phthisis  is  not  be- 
yond the  powers  of  nature  ;  but  it  must  be  admitted,  at  the  same 
time,  that  art  possesses  no  certain  means  of  obtaining  this  de- 
sirable end.  To  be  convinced  of  this,  we  need  only  give  a  glance 
at  the  innumerable  remedies  that  have  been  proposed  for  its  cure.f 
We  may  be  well  assured  that  a  disease  is  irremediable,  when  we 
find  employed  in  its  treatment  almost  every  known  medicament, 
however  different  or  even  opposite  in  effect ;  when  we  see  new 
remedies  proposed  every  day,  and  old  ones  revived,  after  having 
lain  long  in  merited  oblivion ;  when,  in  short,  we  find  no  plan 
constant  but  that  of  giving  palliatives,  and  no  means  persevered 
in,  but  such  as  are  proper  for  fulfilling  indications  purely  symp- 
tomatic.    On  these  grounds,  have  been  alternately  cried  up — 

*  Dr.  Clark's  work  already  quoted,  contains  a  table  exhibiting  the  laws  of 
mortality  in  phthisis.  The  author  supposes  100  persons  in  whom  the  malady 
begins  the  same  moment;  the  first  column  indicates  the  number  of  months  or 
years  elapsed  since  the  commencement  of  the  disease  :  the  second  column, 
the  number  of  individuals  dead  at  the  end  of  three  months,  six  months, 
&c. ;  the  third,  the  number  of  patients  who  survive;  and  the  fourth  shows 
how  many  die  at  different  periods  in  the  course  of  the  disease. 


Time  elapsed  since 
the  commencement 

Died. 

Survived. 

Number  dead  at  different  periods. 

3  months 

8 

92 

8  from     1  month  to     3  inclusive. 

6 

30 

70 

22     "        4           "           6 

9        « 

52 

48 

22    "7           "           9           " 

12        « 

62 

38 

10     "      10           "         12          " 

15        « 

72 

28 

10    "      13          "         15          " 

18 

76 

24 

4     "      16          "        18          " 

24         « 

85 

15 

9    "      19          "        24          " 

5     years 

94 

6 

9     "         3    years  to     5           " 

10        " 

97 

3 

3    «       6          "        16          " 

40 

85 

0 

3    "      11          "        40          " 

t  See  Ploucquet's  Litteratura  Med.  Digesta.  verb.  Phthisis. — Author. 


Jndral . 


TREATMENT. 


337 


alkalis,  and  acids ;  spare  diet  and  rich  animal  diet ;  dry  air  and 
moist  air ;  pure  air  and  air  impregnated  with  fetid  vapors ; 
oxygen,  hydrogen,  and  carbonic  acid;  exercise  and  quiet ;  emol- 
lients and  tonics ;  heat  and  cold  ;  paragorics  and  other  anodynes 
and  stimulants, — not  only  of  the  aromatic  and  antiscorbutic  kind, 
but  the  most  irritating  preparations  of  mercury,  the  sulphate  of 
copper,  arsenic,  &c* 

With  the  view  of  reducing  to  some  order,  so  sterile  a  super- 
fluity, I  shall  enquire,  in  the  first  place,  what  are  the  indications 
to  be  fulfilled  in  the  treatment  of  phthisis  ;  in  the  next  place  I 
shall  enquire  whether  experience  has  led  us  to  the  knowledge  of 
any  means  really  efficacious  in  its  cure  ;  and  lastly,  I  shall  give 
some  account  of  the  means  calculated  to  fulfil  the  symptomatic 
indications.  From  the  facts  formerly  detailed,  exhibiting  the 
mode  in  which  nature  sometimes  cures  phthisis,  it  results,  that 
the  most  rational  indications  should  be,  as  soon  as  we  have  as- 
certained the  existence  of  the  disease,  to  prevent  the  secondary 
eruption  of  tubercles ;  as,  in  this  case,  if  the  primary  tubercular 
masses  were  not  extremely  large  or  numerous,  which  they  very 
seldom  are,  a  cure  would  necessarily  take  place  after  they  are 
softened  and  evacuated.  The  second  indication  should  be,  to 
promote  the  softening  and  evacuation  or  absorption  of  the  exist- 
ing crop  of  tubercles.  Although  the  first  of  these  indications, 
like  the  facts  on  which  it  rests,  is  new,  nevertheless,  all  the  means 
which  have  been  thought  best  calculated  to  fulfil  it,  have  been 
put  in  practice  from  time  immemorial ;  it  having  always  been 
the  common  endeavor  of  physicians,  to  prevent  the  develop- 
ment of  phthisis  in  subjects  threatened  with  it,  either  from  con- 
stitutional predisposition,  or  from  the  actual  presence  of  unpleas- 
ant symptoms.  I  have  formerly  proved  that,  in  the  latter 
class  of  cases,  the  mischief  is  already  done,  inasmuch  as  the 
first  symptoms  general  and  local,  and  even  the  physical  signs,  do 
not  show  themselves  very  often  until  long  after  the  formation  of 
tubercles.  Nevertheless,  I  shall  here  notice  the  means  which 
have  been  in  their  turns,  cried  up  as  calculated  to  prevent  the 
development  of  tubercles.  Of  these,  bleeding  and  derivatives 
are  the  chief.  Stoll  recommends  small  bleedings  frequently  re- 
peated, and  gradually  diminished  in  extent, — a  precept  rendered 
the  more  necessary  by  the  progressive  diminution  of  the  patient's 
strength.  The  greater  number  of  physicians  who  have  employed 
this  remedy,  have  not  considered  it  as  a  means  of  curing  or  even 
preventing  phthisis,  but  only  as  calculated  to  allay  the  inflam- 
matory affections  with  which  this  is  sometimes  complicated.  M. 
Broussais.  however,  has  maintained  the  former  proposition.     "  In 

*  Ploucquet  Op.  Cil 


388  PHTHISIS    PULMONALIS. 

putting  a  stop  (he  says)  to  these  three  kinds  of  inflammation 
(catarrh,  mild  pneumonia,  and  pleurisy,)  by  very  active  treat- 
ment at  their  onset,  I  rendered  the  occurrence  of  phthisis  very 
rare,  whatever  be  the  constitutional  predisposition  of  the  patient." 
(Boct.  Med.  p.  686.)  The  reader  will  be  able  to  judge  of  the 
truth  and  probability  of  this  statement,  from  the  contents  of  the 
preceding  sections.  I  shall  content  myself  with  asserting  briefly, 
in  this  place,  that  bleeding  can  neither  prevent  the  formation  of 
tubercles  nor  cure  them  when  formed.  Tt  ought  never  to  be 
employed  in  the  treatment  of  consumption  except  to  remove  in- 
flammation or  active  determinations  of  blood,  with  which  the 
disease  may  be  complicated  ;  beyond  this,  its  operation  can  only 
tend  to  an  useless  loss  of  strength.*  I  am  even  of  opinion  that  the 
same  reasoning  is  applicable  to  the  catamenial  discharge.  I  have 
already  said  that  the  suppression  of  this  is,  in  most  cases,  the 
effect  and  not  the  cause  of  the  formation  of  tubercles  ;  and  as  long 
as  these  continue  to  form  and  to  increase  in  size,  with  the  attend- 
ant general  symptoms,  it  is  at  least  useless  to  attempt  to  restore 
the  process.  At  the  same  time,  should  there  arise,  in  such  cases, 
a  sufficient  indication  for  tailing  away  blood,  I  am  of  opinion  that 
it  may  be  more  beneficially  obtained  by  the  application  of  leeches 
to  the  inner  part  of  the  thighs,  than  in  any  other  manner. 

The  actual  cautery  and  issues  would  seem  to  present  the  most 
rational  means  for  preventing  the  formation  of  tubercles,  as  well 
primarily  as  a  secondary  eruption  of  them.  This  method  is  very 
ancient.  Hippocrates  directed  four  eschars  with  a  red  hot  iron  be- 
low the  axilla,  on  the  breast  or  back.  Celsus  recommends  six— - 
one  beneath  the  chin,  one  on  the  throat,  on<j  under  each  nipple, 
and  .One  at  the  lower  angle  of  each  scapula.  I  have  used  ex- 
tensively these  cauteries,  both  actual  and  potential,  in  the  treat- 
ment of  phthisis,  and  I  must  confess  that  I  have  never  ob- 
tained a  cure  in  any  case  where  they  were  employed.  I  have 
commonly  applied  them  beneath  the  clavicle,  or  in  the  supra- 
spinal fossa  ;  and  in  some  patients  I  have  repeated  the  applica- 
tion of  the  searing  iron  as  many  as  twelve  or  fifteen  times. 
It  is,  however,  only  a  very  small   number  of  patients  that  will 

*  Bloodletting  has  been  a  favorite  remedy  with  many  physicians  of  great  emi- 
nence. In  this  country,  its  advantages  have  been  strongly  advocated  by  Dover, 
Pringle,  Fothergill,  Stark,  Watt,  and  others.  The  first  and  last  mentioned  au- 
thors carried  the  practice  to  a  very  great  extent ;  and  the  latter  advocated  its 
utility  on  a  most  singular  principle,  viz.  that  of  producing  afebrile  re-action, 
with  the  view  of  "  restoring  the  blood,"  and  thereby  curing  the  disease.  See 
"  Cases  of  Diabetes,"  &c.  by  R.  Watt,  1808,  p.  277.  I  have  seen  bloodletting 
much  employed,  and  have  myself  used  it  much,  in  this  disease.  I  have  seen 
great  benefit  derived  from  it,  but  chiefly  in  relieving  the  inflammatory  complica- 
tions of  phthisis.  With  our  present  knowledge  of  its  pathology,  it  can  hardly 
be  expected  to  benefit  the  tuberculous  affection,  and  my  experience  leads  me  to 
condemn  its  use  in  every  case  of  pure  phthisis.— -Transl. 


TREATMENT. 


389 


submit,  to  a  mode  of  treatment  so  horribly  painful.  Small  moxas, 
of  only  a  line  in  diameter,  applied  two  or  three  at  a  time,  and 
repeatedly,  have  appeared  to  me  more  useful  than'  the  searing 
iron  ;  as  under  their  employment  I  have  sometimes  seen  a  very 
striking  suspension  of  all  the  symptoms.  At  all  events,  I  have 
now  almost  entirely  renounced  the  use  of  the  actual  cautery. 
Measures  so  painful  ought  not  to  be  had  recourse  to,  unless  they 
are  found  by  experience  to  hold  out  a  reasonable  hope  of  success. 
For  this  reason,  I  now  restrict  myself  to  the  application  of  the 
caustic  potass,  in  the  places  above  mentioned,  so  as  to  form 
eschars  of  eight  or  ten  lines  in  diameter  ;  and  I  do  not  even 
insist  upon  this,  if  the  patient  is  very  averse  to  it.  In  regard  to 
blisters  and  permanent  issues,  so  common  in  practice,  I  think  it 
will  be  admitted  by  all  practitioners  that  little  benefit  is  produced 
by  them  after  phthisis  is  fully  formed,  while  they  are  frequently 
very  inconvenient  from  the  local  irritation  which  they  occasion. 
They  ought  never  to  be  applied  to  the  chest  itself;  for,  although 
in  this  situation,  they  sometimes  produce  temporary  relief  when 
there  are  acute  local  pains,  they  too  frequently  give  rise  to  a  de- 
termination of  blood  to  the  thoracic  organs,  and  more  particularly 
occasion  pleurisy.  When  from  custom  or  the  wish  of  the  patient, 
I  prescribe  a  blister,  I  usually  direct  it  to  be  applied  to  the  inner 
part  of  the  thigh  ;  partly  because  this  affords  a  broader  surface 
than  the  arm,  and  because,  in  women,  the  indication  of  restoring 
the  catamenia  gives  it  an  additional  propriety.  Some  prac- 
titioners have  of  late  years  attempted  to  apply  the  cautery  to  the 
verge  of  the  anus,  and  to  produce  an  artificial  fistula  by  means  of 
a  seton.  But  I  have  neither  seen  nor  heard  any  thing  which 
tends  to  render  this  kind  of  derivation  more  useful  than  the  others. 
The  cases  in  which  the  excitement  of  discharges  from  the  skin  is 
most  indicated,  are,  no  doubt,  those  in  which  the  suppression  of 
an  habitual  discharge,  or  the  repulsion  of  a  cutaneous  eruption, 
has  appeared  to  be  the  occasional  cause  of  the  disease.* 

Means  for  promoting  the  softening  of  the  tubercles. — The 
means  which  seem  best  adapted  to  fulfil  this  indication,  have 
been  often  employed  with  other  views,  according  to  the  prevailing 
theory,  and  particularly  with  the  intention  of  healing  the  internal 
ulcers  and  promoting  the  expectoration.  Of  this  kind  is  the 
deobstruent  or  attenuant  alkaline  treatment  formerly  mentioned, 
by  means  of  lime-water,    the  natural  and  artificial  sulphureous 

*  Issues  of  a  very  large  size  have  been  especially  recommended  in  this  coun- 
try by  Dr.  Mudge.  See  his  "  Radical  cure  for  a  cough."  Setons,  perpetual 
blisters,  and  other  external  irritants  have  been  equally  recommended,  used, 
abandoned,  and  again  recommended.  More  lately,  the  tartar  emetic  has  been 
again  strongly  recommended  by  Dr.  Jenner.  See  his  "  Letter  to  Dr.  Parry," 
Land.  1822.  I  have  tried  them  all,  and  I  am  sorry  to  say,  without  any  benefit. — 
Transl. 


390  PHTHISIS    PULMONAL1S. 

waters,  internally  or  externally,  sal  amoniac,  the  subcarbonates 
of  ammonia  and  soda,  nitrate  of  potass,  hydfo-chlorate  of  soda, 
&c*  We  must  admit  that  these  means  sometimes  promote  ex- 
pectoration, and  they  seem  calculated  to  hasten  the  softening  of 
the  tuberculous  matter.  However,  judging  from  their  slowness 
at  least,  and  frequent  inefficacy  against  tubercles  in  the  glands,  we 
ought  hardly  to  expect  much  from  them  in  the  case  of  pulmonary 
tubercles.  The  same  remark  applies  to  the  hydro-chlorate  of 
lime,  the  preparations  of  mercury,  the  hydro-chlorate  of  barytes, 
and  even  the  preparations  of  antimony,  which  are  in  fact  only 
useful  in  promoting  expectoration,  or  in  opposing  an  intercurrent 
pneumonia.  It  is  with  the  view  of  cicatrizing  the  internal 
ulcers  that  different  practitioners  have  recommended  plants  of 
an  antiscorbutic  and  aromatic  kind,  purgatives,  balsamics,  par- 
ticularly the  balsams  of  Tolu,  Peru,  and  Mecca,  turpentine, 
camphor,  sulphur  dissolved  in  volatile  oils,  &c.  The  same  end 
has  been  sought  to  be  attained  by  mixing  with  the  air  breathed 
by  the  patient,  certain  gases,  so  as  to  produce  an  artificial  atmo- 
sphere. The  limited  extent  to  which  such  practices  have  been  car- 
ried, sufficiently  proves  the  little  confidence  to  be  reposed  in  them. 
On  this  principle,  have  been  cried  up,  in  their  turn,  the  vapors 
from  decoctions  of  plants  of  an  emollient,  aromatic,  narcotic,  or 
balsamic  kind ;  the  fumes  of  different  kinds  of  resin  burned  on 
a  hot  iron  or  a  brazier,  particularly  those  of   myrrh,  benzoin, 

*  For  some  remarks  on  the  alkaline  or  deobstruent  treatment  of  diseases,  see 
page  255.  In  the  work  of  Dr.  Farnese  there  referred  to,  (p.  110,)  the  author 
speaks  highly  of  the  powers  of  carbonate  of  potass  (from  a  drachm  to  an  ounce, 
in  half  a  pint  of  water  daily.)  in  phthisis,  and  adduces  his  own  case  as  an  in- 
stance of  a  complete  cure  effected  by  it.  It  is  somewhat  singular  that  among 
the  alleged  deobstruents  or  sorbefacients,  our  author  takes  no  notice  of  one  of 
the  most  potent  of  these,  Iodine.  From  its  remarkable  powers  in  removing 
bronchocele,  and  in  reducing  the  size  of  diseased  lymphatic  glands  on  the  sur- 
face of  the  body,  the  employment  of  Iodine  in  pulmonary  tubercles,  was  at  once 
prompted  and  justified  by  the  fairest  analogy.  As  far  as  I  know,  Dr.  Baron 
was  the  first  to  make  trial  of  it  in  this  case  (see  "  Illustrations  of  the  enquiry 
respecting  tuberculous  diseases,"  p.  225)  ;  and  the  only  accounts  I  have  met 
with  of  its  effects  in  phthisis,  are  those  given  in  his  work,  and  in  a  small 
pamphlet  by  Dr.  Gardiner,  "  On  the  effects  of  Iodine,"  published  in  1824 
Both  these  accounts,  however,  are  extremely  meagre,  and  afford  no  ground  for 
expecting  benefit  from  this  remedy,  beyond  what  were  already  supplied  by 
analogy.  It  is,  however,  certainly  deserving  of  further  trial;  more  especially 
since  the  case  may  be  fairly  considered  as  hopeless,  and  since  the  researches  of 
several  physicians,  as  well  in  this  country  as  on  the  continent,  have  proved  this 
new  remedy  to  be  efficacious  in  many  other  diseases  besides  bronchocele.  See 
particularly,  professor  Brera's  Saggio'  clinico  suW  Iodio,  Padua,  1822,  Dr.  Man- 
son's  Medical  Researches  on  Iodine,  Lond.  1825,  and  above  all  Lugol's  recent 
work  on  Scrofula,  translated  by  Dr.  O'Shaughnessey.  I  have  myself  used  iodine 
very  extensively  in  bronchocele  (which  is  endemic  in  many  parts  of  Sussex), 
and  with  almost  uniform  success.  I  must  say,  however,  that  my  experience  as 
to  its  occasionally  injurious  effects  on  the  system,  is  more  in  accordance  with 
that  of  Brera  than  of  Dr.  Manson.—  Transl.  * 


TREATMENT. 


391 


petroleum,  tar,*  and  resin  intermixed  with  wax,  &c. ;  the  air  of 
cow-houses ;  the  vapors  produced  by  the  sublimation  of  zinc* 
lead,  sulphur,  &c.  Under  the  same  head  we  may  reckon  the 
inspiration  of  the  different  gases,  by  means  of  an  appropriate 
apparatus,  viz.  oxygen,  hydrogen,  sulphurated  hydrogen,  car- 
bonic acid  ;  and  also  air  charged  with  mephitic  vapors,  such  as 
that  of  stagnant  water,  the  snuff  of  candles,  &c.f 

It  is]  more  than  probable  that  a  great  number  of  the  cases  in 
which  these  various  means  have  seemed  successful,  were  mere 
chronic  catarrhs ;  and  it  is  possible  that,  from  a  peculiar  idio- 
syncracy  in  particular  persons,  even  the  most  absurd  of  these  may 
have  been  beneficial,  at  least  as  palliatives,  in  changing  for  a  time 
the  existing  character  of  the  sensibility  of  the  lungs,  and 
relieving  some  distressing  symptoms.  T  have  frequently  known 
the  inspiration  of  stimulant  vapors  put  an  end  to  the  pains  of 
the  chest  or  dyspnoea,  after  narcotic  and  emollient  vapors  had 
been  employed  without  success. 

Empirical  means.  A  great  many  of  the  remedies  already 
mentioned  might  very  properly  be  ranged  under  this  head,  al- 

*  For  a  full  account  of  the  mode  of  using,  and  the  alleged  utility  of  tar  vapor, 
I  refer  the  reader  to  Sir  A.  Crichton's  "  Practical  observations  on  Consump- 
tion." Lond.  1823.  (See  also  the  note,  p.  85.)  I  have  made  some  trial  of  this 
remedy,  without  benefit  certainly,  in  every  case,  and  occasionally  with  tempo- 
rary increase  of  cough  and  irritation. —  Transl. 

t  The  inhalation  of  Chlorine,  noticed  in  a  former  note  (p.  85)  first  introduced 
by  M.  Gannal,  has  been  much  used  of  late  years  in  the  different  stages  of 
phthisis,  but  with  effects  extremely  problematical.  The  facts  adduced  by  M. 
Gannal  are  any  thing  but  conclusive  :  most  of  his  patients  had  only  chronic  ca- 
tarrhs, and  where  phthisis  evidently  existed,  no  cure  ensued.  (Revue  Med. 
Fcv.  Aoti,  1828.)  Those  adduced  by  M.  Bayle  in  the  same  Journal  (Nov.  1829) 
prove  nothing  more  :  out  of  twelve  patients  only  one  was  cured,  and  there  ex- 
isted no  certain  proof  that  this  was  a  case  of  true  phthisis.  I  say  nothing  of 
certain  other  cases  of  cured  phthisis  published  in  some  half-medical  journals, 
as  they  are  so  loaded  with  the  varnish  of  quackery  that  it  is  impossible  to  put 
any  faith  in  them.  On  the  other  hand,  scrupulous  and  impartial  observers, 
among  whom  1  would  name  my  brother,  Dr.  Ambroise  Laennec  of  Nantes,  Dr. 
Toulmouche  of  Rennes,  and  Drs.  Flandin  and  Miguel  of  Paris,  have  adminis- 
tered the  chlorine  gas  to  a  considerable  number  of  phthisical  subjects,  not  only 
without  success,  but  sometimes  with  positive  disadvantage.  I  have  myself  fre- 
quently employed  it,  without  ill  effects  certainly,  but  without  any  benefit  what- 
ever. All  my  patients,  it  is  true,  were  pectoriloquous,  and  in  this  stage  of  the 
disease  M.  Gannal  says  the  remedy  is  not  effective  :  but  surely  if  it  were  capa- 
ble of  discussing  crude  tubercles,  it  would  be  no  less  able  to  produce  cicatriza- 
tion of  tuberculous  excavations. — (M.  L.) 

I  do  not  think  the  concluding  inference  of  my  brother  annotator  quite  legiti- 
mate, as  it  is  very  conceivable  that  tubercles  may  be  absorbed  from  a  tissue 
otherwise  comparatively  sound,  and  yet  that  an  ulcer  which  succeeds  to  them 
may  not  be  healed  by  the  same  means.  I,  however,  entirely  subscribe  to  the 
judgment  he  has  passed  upon  the  inhalation  of  chlorine,  as  far  as  we  are  borne 
out  by  experience  of  its  practical  effects  :  and  it  is  painful  to  be  obliged  to  add, 
that  almost  the  only  accounts  we  have  of  the  effects  of  the  inhalation  of  chlo- 
rine, simply,  or  in  combination  with  other  matters,  published  by  English  physi- 
cians, arc  so  rased  in  what  Dr.  M.  Laennec  calls  i;  the  varnish  of  quackery,'' 
that  they  are  alike  unworthy  of  the  notice  of  the  philosophical  pathologist  and 
the  honest  practitioner. —  Transl. 


392  PHTHISIS    PULMONALIS. 

though  an  attempt  has  been  made  to  class  them  according  to  the 
indications  they  are  supposed  capable  of  fulfilling.  I  shall  con- 
tent myself  with  merely  enumerating  several  others,  the  inefficacy 
of  which  has  been  sufficiently  demonstrated.  Of  this  kind  are — 
mercurial  salivation ;  emetics  frequently  repeated,  or  continued 
for  a  long  period  in  doses  sufficient  to  excite  nausea  merely  ; 
acorns,  roasted  or  raw ;  charcoal ;  different  kinds  of  mushrooms, 
and  among  others,  the  boletus  suaveolens  and  the  agariciis  pipe- 
ratus  and  deliciosus  ;  red  cabbage  ;  crabs,  oysters,  and  other 
shell-fish  ;  frogs  ;  vipers  ;  chocolate  ;  the  conserve  and  sugar  of 
roses  in  large  doses  ;  wine  and  spirits  ;  sudorifics  ;  electricity  ; 
millepedes  ;  opium  ;  cicuta ;  wolfsbane ;  cinchona ;  the  seeds  of 
the  phellandrium  aquaticum ;  the  preparations  of  lead;  hydro- 
cyanic acid  ;*  the  swing,  formerly  recommended  by  Themison 
(apud  Csel :  Aurel.)  and  revived  by  the  moderns,  &c.  &c. 

Of  all  the  measures  hitherto  recommended  for  the  cure  of 
phthisis,  none  has  been  followed  more  frequently  by  the  suspen- 
sion or  complete  cessation  of  the  disease,  than  change  of  situation. f 

*  Hydrocyanic  acid,  as  existing  in  laurel  water,  appears  to  have  been  employ- 
ed as  a  remedy  for  coughs  and  consumption  before  the  middle  of  last  century. 
After  the  discovery  of  the  acid  in  the  beginning  of  the  present  century,  it  was 
employed  by  the  Italian  physicians,  particularly  Brera,  as  a  sedative,  in  diseases 
of  excitement,  and  also  in  coughs  and  tubercular  phthisis.  About  ten  years 
since,  it  was  introduced  more  particularly  to  the  notice  of  the  profession,  by  M. 
Magendie,  in  France,  and  Dr.  Granville,  in  England,  and  was  at  the  time,  and 
has  been  since,  very  extensively  used  in  phthisis.  I  have  myself  used  it ;  and  re- 
gret to  think,  that  the  results  not  merely  of  my  own  experience,  but  those  even 
of  its  best  advocates,  when  critically  examined,  lead  to  the  conclusion,  which 
might  have  been  anticipated,  that  it  is  utterly  powerless  in  curing  tuberculous 
consumption.  As  a  sedative,  it  is  certainly  occasionally  useful  in  quieting  the 
cough.  See  Dr.  Granville's  "  Historical  and  Practical  Treatise  on  Hydrocyanic 
acid."     Second  Ed.  London.  1820. —  Transl. 

t  During  a  residence  of  five  years  at  Penzance  in  Cornwall,  a  place  much  fre- 
quented by  consumptive  patients,  on  account  of  the  extreme  mildness  and  equa- 
bility of  its  temperature,  I  had  extensive  opportunities  of  observing  the  effect  of 
change  of  climate  in  phthisis;  and  I  am  sorry  to  say  that,  in  the  greater  Dumber 
of  cases,  the  change  was  not  beneficial.  This  result,  however,  must  not,  in  fair- 
ness, be  considered  as  derogating,  in  any  considerable  degree,  either  from  the 
propriety  of  the  practice  or  the  fitness  of  the  situation ;  since  it  must  be  confes- 
sed, that  very  few  of  the  invalids  came  to  Penzance  in  that  period  of  the  disease 
when  a  cure  could  be  expected,  if,  indeed,  it  were  even  possible.  In  no  case  of 
well-marked  tubercular  phthisis,  did  I  witness  a  cure,  or  even  a  temporary  alle- 
viation, that  could  fairly  be  attributed  to  change  of  climate.  In  a  good  many 
cases,  however,  of  chronic  bronchitis,  simulating  phthisis,  the  health  was  greatly 
improved,  and  in  some  it  was  completely  restored,  from  a  state  of  great  debility 
and  seeming  danger.  In  a  few  cases,  also,  of  young  persons  who  accompanied 
their  diseased  relatives,  and  in  whom  the  hereditary  predisposition  was  strongly 
marked,  if  there  was  not  already  evidence  of  nascent  tubercles, — a  great  and 
striking  improvement  in  the  general  health  and  strength,  followed  within  a  short 
period  after  their  arrival,  and  seemed  fairly  attributable  to  the  combined  influ- 
ence of  change  of  air,  scene  and  habits.  In  point  of  mildness  and  equability  of 
temperature,  Penzance  exceeds  every  other  situation  frequented  by  invalids  in 
this  island,  and  comes  not  very  far  short,  in  this  respect,  of  some  places  in  the 
south  of  France  and  north  of  Italy.  (See  my  "  Observations  on  the  climate  of 
Penzance."'     Lond.  1820.)     Like  the   whole  south  of  England,  however,  it   is 


TREATMENT. 


393 


It  is  even  probable  that  the  good  effects  of  mineral  waters  are 
partly  owing  to  this  cause  ;  since  we  find  that  these  are  by  them- 

very  inferior  to  the  places  just  mentioned  in  point  of  dryness,  the  number  of 
days  on  which  rain  falls  being  very  great ;  and  on  this  account,  the  benefit  to  be 
expected  from  its  mildness  of  temperature,  is  often  more  than  counterbalanced 
by  the  frequent  inability  of  the  invalid  to  take  exercise  in  the  open  air.  It  is 
proper  to  mention  that,  as  at  Marseilles,  Nice,  Rome,  and  other  favorite  spots  on 
the  continent,  consumption  is  as  frequent  at  Penzance  as  elsewhere. 

For  the  succeeding  portion  of  this  note  I  am  indebted  to  my  friend  Dr.  Clark, 
late  of  Rome,  but  now  resident  in  London  ;  whose  opportunities  of  witnessing 
the  influence  of  climate  in  consumption,  have  been,  perhaps,  unequalled,  and 
whose  accuracy  of  observation  and  soundness  of  judgment  are,  at  least,  equal  to 
his  opportunities.  I  am  happy  to  say  that  Dr.  Clark  is,  at  this  time,  preparing 
for  publication  a  work  on  the  effect  of  climate  on  consumption  and  other  dis- 
eases, which,  I  doubt  not,  will  throw  great  light  on  the  subject  now  under  con- 
sideration. 

"  I  consider  consumption,  with  your  distinguished  author,  as  a  disease  very 
generally  consequent  to  a  deranged  or  cachectic  state  of  the  general  system,  ori- 
ginating in  a  series  of  functional  disorders,  and  often  favored  by  an  hereditary 
predisposition  to  tubercles.  When  adopted  for  the  removal  of  this  state  of  the 
system,  and  previously  to  the  actual  development  of  tubercles  in  the  lungs,  I 
look  upon  change  to  a  milder  climate  as  a  measure  of  the  utmost  importance,  and 
likely  when  well-timed  and  combined  with  such  other  treatment  as  the  case  may 
require,  to  go  a  great  way  to  the  attainment  of  this  most  desirable  object.  If  the 
mischief  has  advanced  a  little  further,  and  there  are  good  reasons  for  believing 
that  tubercles  are  already  formed  in  the  lungs,  more  especially  if  a  disposition  to 
inflammation  of  these  organs  or  to  haemoptysis  has  manifested  itself;  then, 
change  of  climate  becomes  a  more  doubtful  measure;  and,  unless  adopted  with 
judgment  and  with  some  precaution,  may  accelerate  rather  than  retard  the  pro- 
gress of  the  disease.  In  cases  of  this  kind,  it  will  he  necessary,  previously  to 
undertaking  the  journey,  to  remove,  or  at  least  to  moderate,  the  more  evident 
and  important  of  the  functional  derangements,  to  subdue  excitement,  and  dimin- 
ish plethora.  Much  evil  has  arisen  from  inattention  to  these  precautions. 
Medical  men  in  general  seem  hardly  sufficiently  aware  of  the  great  excitement 
produced  in  the  system  by  travelling,  and  of  the  necessity,  therefore,  of  remov- 
ing those  morbid  complications  most  likely  to  suffer  aggravation  from  this.  If 
the  disease  has  made  still  greater  progress,  and  the  cough,  expectoration,  ema- 
ciation, hectic  fever,  and  the  results  of  auscultation,  leave  no  doubt  of  the  ad- 
vanced stage  of  the  tubercles,  the  mischief  to  be  apprehended  from  the  exposure, 
the  fatigue,  the  irritation  and  excitement  of  a  long  journey,  is  greatly  increased ; 
and  under  such  circumstances,  generally  speaking,  no  advantage  is  to  be  ex- 
pected from  the  change,  and  very  often  the  fatal  termination  will  be  accelerated 
by  it.  But  should  the  symptoms  just  enumerated,  from  whatever  cause,  have 
become  much  mitigated,  and  more  especially  if  there  is  reason  to  believe,  from 
a  careful  examination  of  the  chest,  that  the  disease  is  confined  to  a  small  portion 
of  the  lungs;  then,  a  residence  in  a  milder  climate  affords  the  best  opportunity 
of  aiding  the  efforts  of  nature  in  the  work  of  reparation;  and,  by  contributing  to 
the  re-establishment  of  the  general  health,  will  tend  to  prevent  the  further  for- 
mation of  tubercles. 

"  A  change  of  climate  having  been  decided  on,  the  particular  situation  to  be 
selected  becomes  a  question.  Professor  Laennec's  decided  preference  of  a  mari- 
time residence  is  not,  perhaps,  founded  on  a  very  extensive  experience;  certain 
it  is,  however,  that,  as  well  in  this  country  as  on  the  continent,  the  places  usu- 
ally resorted  to  by  consumptive  invalids,  are  on  the  sea-coast,  or  at  no  great  dis- 
tance from  it.  On  the  continent,  the  places  chiefly  frequented,  and  which  I 
have  had  an  opportunity  of  observing,  are  Hyeres  in  the  south  of  France,  Nice 
in  Piedmont,  Pisa.  Rome,  and  Naples  in  Italy-  Each  of  these  places  may  have 
some  advantages  when  compared  with  the  others,  and  when  considered  in  ref- 
erence to  each  individual  case.  The  constitution  of  the  patient,  the  co-existence 
of  other  diseased  states  with  the  pulmonary  affection,  the  previous  abode  and 
habits  of  the  patient,  &e.  &c.  must  be  taken  into  account  in  fixing  the  decision. 

50 


394  PHTHISIS    PULMONALIS. 

selves  of  only  very  dubious  efficacy,  while  many  consumptive 
persons  find  themselves  benefited  by  a  residence  in  their  vicinity, 
although  unable  to  take  the  waters  either  internally  or  externally. 
We  find,  however,  that  the  air  of  mountains  is  far  from  agreeing 
with  all  consumptive  patients ;  and  it  seems  probable  that  those 
with  whom  it  agrees  have  only  a  small  number  of  tubercles  in  the 
lungs :  since  it  would  appear  that  though  phthisis  is  infrequent 
in  mountainous  countries,  when  it  occurs,  it  runs  a  very  rapid 
course.  The  air  of  the  country  agrees  in  general  better  than 
that  of  the  town ;  and  the  air  of  warm  climates  better  than  that 
of  cold.  A  residence  by  the  sea  side,  particularly  in  mild  and 
temperate  climates,  is  unquestionably  the  situation  in  which  most 
consumptive  patients  have  been  known  to  recover.  On  this  point 
both  the  ancients  and  the  moderns  seem  agreed.  Aretaeus  re- 
commends sailing,  and  the  air  of  the  seashore.  Celsus  advises  a 
voyage  to  Egypt.  For  a  vast  number  of  years,  the  physicians 
of  nearly  the  whole  of  Europe  have  sent  their  patients  to  Hyeres 
and  Nice ;  and  in  addition  to  these,  the  English  recommend  the 
coast  of  Devonshire  and  the  Canary  Islands.  I  formerly  men- 
tioned the  infrequency  of  phthisis  on  the  coast  of  Bretagne.  In- 
deed, I  am  convinced,  that  in  the  actual  state  of  our  knowledge, 
we  have  no  better  means  to  oppose  to  this  disease,  than  a  sea 
voyage  and  a  residence  on  the  seacoast,  in  a  mild  climate  ;  and, 
accordingly,  I  always  recommend  these  when  practicable.  Last 
winter  I  made  an  attempt  in  a  small  ward  of  the  Clinical  Hos- 
pital, to  establish  an  artificial  marine  atmosphere  by  means  of 
fresh  sea-weed  (fucus  verrucosus).  Twelve  consumptive  patients 
were  subjected  to  this  treatment  for  four  months.  In  all  of  them 
the  disease  remained  stationary  ;  and  in  some,  the  emaciation  and 
hectic  fever  were  sensibly  lessened.  Nine  of  them,  considering 
themselves  cured,  left  the  hospital,  although  I  must  admit  that 
only  one  of  these  afforded  any  real  hope  of  cure.  Our  supply 
of  sea  weed  having  failed  towards  spring,  owing  to  the  difficulty 
of  conveying  it,  the  disease,  from  this  time,  assumed  a  rapid  pro- 

In  almost  every  case,  when  the  removal  to  a  milder  climate  can  be  conveniently 
effected   by  sea,  this  means  is  much    preferable  to  a  journey  by  land;    in  some 
cases,  the  good  effects  produced  by  a  voyage  are  very  remarkable." 
George  Street,  May  2nd,  1827. 
Since  the  date  of  the   foregoing    note,  Dr.  Clark  has  given   to  the  world  his 
invaluable  work  on  the  Influence  of  Climate  in  Chronic  Diseases,  a  work  which 
contains  much  more  useful   practical    knowledge    respecting  the    treatment  of 
phthisis.     More  recently,  the  same  distinguished   physician   has  enriched  the 
Cyclopedia  of  Practical   Medicine  with  a  complete  Treatise  on  Consumption 
(vol.  iv.  Supplement ,)  which  leaves  at  a  great  distance,  as  to  accurate  and  com- 
prehensive pathological  views  and  the  true  principles  of  prevention  and  treat- 
ment, every  work  hitherto  published  on  the  subject.     It  is  to  be  hoped  that  Dr. 
Clark  will  soon  publish  this  treatise  in  a  separate  form.— Trand. 


TREATMENT. 


395 


gress  in  the  three  remaining  patients,  and  speedily  carried  them 
to  the  grave.* 

Palliative  treatment  of  symptoms. — If  we  are  destitute  of  every 
direct  and  effectual  means  of  resisting  this  disease,  we  are,  at 
least  able,  in  many  cases,  to  alleviate  its  troublesome  symptoms, 
such  as  the  cough,  dyspnoea,  night  sweats,  and  diarrhoea.  For 
quieting  the  cough,  emollient  drinks,  and  alimentary  matters  of 
a  mucilaginous  nature,  have  been  always  in  use, — such  as  milk, 
(woman's,  ass's,  cow's,  goat's,  mare's,)  saloop,  sago,  gum,  Iceland 
moss,  potato-starch,  arrow-root,  barley,  rice,  sugar,  and  the  infu- 
sions of  inert  mucilaginous  plants,  properly  sweetened.  When* 
the  cough  is  dry,  and  the  expectoration  difficult,  also  when  there 
is  a  want  of  sleep,  opium  in  small  doses,  or  any  other  narcotic 
extract,  is  added  with  advantage.  The  hydrocyanic  acid  also 
sometimes  succeeds  very  well  in  relieving  the  cough  and  even 
the  dyspnoea  ;  but  its  effects  are  less  certain  than  those  of  opium. 
Antimonials,  although  at  different  times  much  cried  up,  have 
never  appeared  to  me  of  great  efficacy,  even  in  aiding  expectora- 
tion. The  diarrhoea  must  be  also  treated  by  mucilaginous  drinks, 
and  the  milder  preparations  of  opium.  However,  when  it  de- 
pends on  the  presence  of  tuberculous  ulcers  in  the  intestines,  as  it 
almost  always  does,  we  can  only  hope  at  best  to  suspend  its  vio- 
lence ;  and  we  cannot  always  even  effect  this.  The  acetate  of 
lead  appears  sometimes  to  moderate  this  symptom ;  but  it  is 
much  more  efficacious  in  lessening  the  perspirations  :  indeed  it  is 
almost  the  only  means  we  can  oppose  to  these.  Dyspnoea  must 
be  combated  by  the  preparations  of  opium  and  other  narcotic 
plants.  The  hydrocyanic  acid  and  musk  are  also  sometimes 
beneficial  in  this  respect.  I  speak  not  here  of  pulmonary  con- 
gestions, whether  terminating  in  inflammation,  haemorrhage,  or 
serous  effusion.  I  shall*  merely  remark,  that,  in  these  cases,  we 
must  not  take  away  more  blood  than  is  absolutely  necessary  to 
relieve  the  symptoms,  since  bleedings,  either  too  copious  or  too 
frequent,  have -an  evident  effect  in  accelerating  the  progress  of 
the  disease. 

*  I  cannot  pass,  without  remark,  the  imbecility  of  this  statement,  and  the 
over-weening  and  unjustifiable  confidence  in  the  principle  on  which  the  prac- 
tice was  founded.  If"  a  marine  atmosphere"  alone  sufficed  for  the  cure  of  phthi- 
sis, happy  would  it  be  for  us  and  all  other  islanders,  who  could  so  easily  enjoy 
the  benefit  of  its  influence,  in  all  its  natural  perfection,  and  without  the  aid 
of  stinking  sea-weed  !  But  not  only  are  the  inhabitants  of  coasts  and  islands  as 
much  subject  to  phthisis  as  those  of  inland  countries,  but  even  those  who  might 
seem  placed  in  the  most  favorable  of  all  circumstances  for  escaping  this  mala- 
dy,— I  mean,  the  natives  of  small  islands  in  mild  and  warm  climates ;  for  in- 
stance, Malta,  Madeira,  and  the  other  Atlantic  islands.  See  Dr.  Sutton's  pa- 
pers in  the  Lond.  Med.  and  Phys.  Journ.  for  March  and  August,  1815,  and  June 
1817;  Dr.  Gourlay's  i;  Observations  on  Madeira,"  Lond.  1811  ;  Dr.  Clark's  In- 
fluence of  Climate,  &c. —  Transl. 


396  PHTHISIS    PULMONALIS. 

From  all  that  goes  before,  1  think  we  must  come  to  the  con- 
clusion recorded  in  the  beginning  of  this  section,  that  although 
the  cure  of  tuberculous  phthisis  be  possible  for  nature,  it  is  not 
so  for  medicine.  Even  the  most  rational  of  our  indications,  that 
of  derivation,  obtains  no  support  from  experience.  Nor  is  this 
the  mode  followed  by  nature  in  her  cures,  as  we  very  seldom  find 
any  evacuation  coinciding  with  the  convalescence  :  the  return  of 
the  catamenia,  or  haemorrhoids,  is  rather  the  effect  than  the  cause 
of  the  cure.  In  order  to  make  a  direct  attack  upon  the  disease,  we 
ought  probably  to  be  able  to  correct  an  unknown  alteration  in 
the  assimilation  or  nutrition,  that  is,  an  alteration  in  the  state  of 
the  fluids  of  the  body.* 

*  The  result  of  all  our  knowledge  of  the  pathology  of  phthisis,  and  of  all  our 
experience  in  the  treatment  of  it,  leading  to  the  conclusion,  that  it  is  incurable 
by  art,  after  tubercles  are  once  developed, — the  only  part  of  the  subject  that  is 
really  of  any  practical  importance  is,  the  plan  to  be  adopted  in  individuals  pre- 
disposed to  the  disease,  with  the  view  of  obviating  the  formation  of  these  ex- 
traneous bodies  :  and  this  is  a  part  of  the  subject  which  our  author  has  left  un- 
touched. Whatever  be  the  proximate  cause  of  tubercles,  or  whatever  may  be 
the  precise  condition  of  ihe  whole  system,  or  of  the  lungs,  which,  as  applied 
to  phthisis,  we  comprehend  under  the  term  predisposition,  there  seems  every 
reason  for  concluding,  not  only  from  analogy,  but  experience,  that  it  is  a  mor- 
bid condition,  which  is,  jn  many  cases,  susceptible  of  being  induced,  aggravated, 
or  removed.  This  conclusion  seems  borne  out  by  the  familiar  facts — of  all  the 
children  of  a  consumptive  family  dying  of  the  disease,  except  perhaps  one  or 
two,  while  in  families  not  at  all  predisposed  to  phthisis,  one  child  out  of  many 
shall  be  alone  affected ;  and  the  conclusion  is  at  once  strengthened  and  render- 
ed of  infinitely  more  importance  by  this  additional  fact,  also  not  very  uncom- 
mon, of  the  children  so  dying,  or  so  escaping,  having  been  subjected  to  a  pe- 
culiar in»de  of  treatment.  Many  facts  observed  in  veterinary  medicine,  add 
irresistible  evidence  to  the  truth  of  this  conclusion.  "  It  is  certain,  from  the 
experiments  of  Dr.  Jenner,  that  we  can,  by  unsuitable  food,  soon  call  up  a  tu- 
berculous disease  in  rabbits  ;  and  it  is  equally  well  known,  that  a  wet  season 
and  bad  pasture  will  bring  into  existence  the  same  disease,  to  a  much  greater 
extent,  in  sheep  and  other  animals.  It  is,  besides,  ascertained,  that  the  disease 
in  both  cases  may  be  got  rid  of  (protided  it  be  not  permitted  to  advance  too  far) 
by  3  more  wholesome  diet,  and  judicious  removal  from  the  influence  of  the 
other  predisposing  causes." — Dr.  Baron's  "  Illustration  of  the  Enquiry,''  <Jfcc.  p. 
212.  Although  there  can  be  little  doubt  that  Dr.  B.  has,  in  this  extract,  mis- 
taken vesicular  worms,  or  hydatids,  for  tubercles  ;  still  the  fact,  though  posses- 
sing the  force  of  analogy  only,  is  one  of  high  value  in  the  present  inquiry.  In- 
deed, all  our  facts  and  reasoning  point  not  merely  to  the  necessity  of  watching 
the  very  first  and  slightest  symptoms  of  incipient  consumption,  but  of  subject- 
ing every  child  which  seems  predisposed  to  it,  whether  from  hereditary  or  ac- 
quired causes,  to  a  most  rigid  system  of  prophylactic  ;  discipline.  For  some 
most  valuable  observations  on  this  subject,  I  refer  the  reader  to  Dr.  Baron's 
work,  just  quoted,  and  regret  that  my  limits  will  only  permit  me  to  extract  a 
single  sentence.  "  Since  it  appears  (says  Dr.  Baron)  that  whatever  enfeebles  the 
frame,  or  deteriorates  the  constitution,  predisposes  to  the  diseases  in  question, 
how  shall  we  avert  this  predisposition  ?  The  answer  is  apparent :  we  must 
do  every  thing  in  our  power  to  invigorate  and  fortify  the  frame  ;  to  bring  all 
its  functions  into  a  healthy  state ;  and  by  all  means  to  endeavor  to  keep 
them  so." — Op.  Cit.  p.  215.  In  these  few  words,  we  have  unfolded  the  germ 
of  a  system  of  prophylactic  treatment,  which  I  have  long  advocated,  and  of  the 
incalculable  importance  of  which  I  have  become  every  day  more  convinced,  not 
merely  by  observation  of  its  value,  even  when  most  imperfectly  applied,  but 
by  the  deep  conviction,  founded  on  no   slight  experience,  that  every  measure 


TREATMENT. 


397 


hitherto  proposed  for  the  removal  of  tubercles  in  the  lungs,  after  they  are  fully 
developed,  is  utterly  valueless.  While  enforcing  a  system  of  invigoration  in 
these  cases,  I  must  caution  the  young  practitioner  against  the  administration  of 
stimulant  food  or  medicine,  when  there  exists  any  inflammatory  complication, 
more  especially  of  the  stomach.  When  such  a  complication  exists,  I  need 
hardly  observe,  that  what  are  usually  denominated  tonics,  will  act  as  the  most 
powerful  debilitants,  and  that  for  the  preservation  or  restoration  of  the  strength, 
we  must  rely  on  abstinence  and  depletion.  See  p.  295.  Here  again  I  must  refer 
the  reader  to  Dr.  Clark's  invaluable  treatise  for  the  development  of  the  prin- 
ciples   and  means  of  prophylaxis. —  Transl. 

The  treatment  of  pulmonary  phthisis  has  this  great  difficulty : — we  en- 
counter constantly  two  distinct  morbid  elements,  one  of  which  demands  a 
remedy  unsuitable  to  the  other.  On  the  one  hand  in  fact,  as  the  disease  passes 
through  its  different  stages,  many  organs  show  a  disposition  more  and  more 
plain,  toward  irritation,  active  congestion  and  inflammation ;  and  from  the  very 
beginning  of  the  malady,  the  cause  which  produces  the  tubercles  in  the  lungs 
occasions  an  inflammatory  action  around  them,  which  increases  in  proportion  as 
these  bodies  augment  and  multiply.  On  the  other  hand,  the  immediate  cause 
of  the  development  of  tubercles,  that  without  which  all  the  others  would  have 
no  effect,  does  not  act  certainly  in  the  manner  of  stimulating  agents:  and  it  is 
more  often  in  a  general  weakness  of  the  system  than  any  other  circumstance 
that  we  are  to  look  for  the  cause  of  tubercles  either  in  the  lungs  or  any  where 
else.  In  the  treatment,  therefore,  while  we  undertake  to  oppose  the  inflamma- 
tory element,  which  is  always  in  activity,  we  must  be  careful  not  to  create  or 
augment  in  the  system  a  state  of  asthenia,  which  has  a  remarkable  tendency  to 
assist  the  development  of  tubercles.  With  this  understanding,  it  will  be  per- 
ceived that  the  treatment,  whether  preventive,  palliative,  or  in  some  cases 
curative,  of  pulmonary  phthisis,  should  not  always  be  the  same.  There  are 
individuals  in  whom  there  is  a  disposition  toward  inflammation,  which  if  it 
becomes  established,  will  be  an  active  occasional  cause  of  tuberculization.  In 
these  cases,  gentle  remedies,  and  antiphlogistics,  employed  to  a  certain  extent, 
form  the  best  treatment ;  a  milk  diet  is  also  useful.  There  are  other  cases 
where  indications  altogether  different  present  themselves ;  here  a  treatment 
purely  debilitating  would  be  eminently  hurtful ;  bloodletting  would  be  very  bad, 
although  advantageous  in  the  first  mentioned  cases,  provided  it  be  not  repeated 
too  often.  In  this  second  class  are  to  be  found  those  individuals  who,  threat- 
ened with  phthisis,  find  their  disorder  aggravated  in  a  remarkable  manner  under 
the  influence  of  sulphureous,  ferruginous,  and  balsamic  preparation,  &c.  Here 
also  a  milk  diet  is  improper.  It  is  not  surprising  therefore,  to  see  the  symptoms 
of  phthisis  in  its  early  stage  improve  and  become  suspended  under  the  influence 
of  remedies  of  a  contrary  nature.  We  hear  of  remedies  against  pulmonary 
phthisis  being  found  in  certain  substances  which  have  been  regarded  as  almost 
specifics  in  this  malady.  For  some  years,  use  has  been  made  of  hydrocyanic 
acid,  chlorine  breathed  or  swallowed,  iodine,  and  more  recently,  creosote.  I 
have  administered  all  these  sufficiently  often  to  affirm  that  none  of  them 
can  cure  the  disease,  but  all  may  be  employed  to  combat  certain  symptoms  and 
perform  a  certain  part  in  the  treatment.  In  this  manner  I  have  known 
hydrocyanic  acid,  in  more  than  one  instance,  to  abate  the  dyspnoea,  diminish 
the  fits  of  coughing,  and  render  it  less  painful.  Thus,  the  inhaling  of  chlorine 
may  modify  advantageously  the  secretion  of  the  bronchi  and  cavities;  iodine 
may  also  be  administered  to  patients  who,  more  or  less  immediately  threatened 
with  a  pectoral  ailment,  are  not  very  irritable,  and  exhibit  in  a  strong  degree 
the  marks  of  a  scrofulous  affection. 

Our  approbation  is  due  to  the  sagacious  remarks  of  Laennec  in  the  preceding 
chapter  on  the  treatment  of  phthisis;  he  has  in  particular,  properly  appreciated 
the  utility  of  bleeding  and  emetics  in  this  disease.  Yet  we  may  note  it  as  a 
singularity,  that  he  recommends  to  promote  the  softening  of  the  tubercles  :  ought 
we  not,  on  the  contrary,  to  use  all  possible  means  to  delay  the  moment  when 
this  softening  is  to  begin,  as  in  many  cases  it  is  at  that  precise  point  the  disease 
puts  on  a  face  decidedly  serious,  or  latent  before,  begins  to  show  itself  by  symp- 
toms no  longer  to  be  mistaken  ? — Andrei. 


398  PHTHISIS     PULMONALIS. 


LITERATURE  OF  PHTHISIS  PULMONALIS. 

1647.  Garencieres     (Theoph.     de)    Angliae   Flagellum   seu   Tabes   Anglica. — 

Lond.  4to. 
1656.  Bennet    (ChrJ    Theatrum   Tabidorurn   sive    Phthiseos    Xenodochium. — 

Lond.  8vo. 
1666.  Harvey  (G.)  Morbus  Anglicus,  or  the  Anatomy  of  Consumption.  Lond.  8vo. 
1677.  Maynwaring  (Ev.)  A  Treatise  of  Consumptions.     Lond.  8vo. 
1682.  Haworth    (S.,  M.  D.)    The   True   Method   of   Curing   Consumptions.— 

Lond.  12mo. 

1684.  Archer  (John,  M.D.)  Secrets  disclosed,  or  a  Treat,  of  Consump.  Lond.  8vo. 

1685.  Byfield  (T.,  M.D.)  Two  Discourses;  one  of  Consumptions.     Lond.  4to. 
1689.   Morton  (Rich.,  M.D.)  Phthisiologia.     Lond.  8vo. 

1697.  Nevett  (Th.,  M.D.)  A  Treatise  of  Consumptions.     Lond.  8vo. 

1700.  Needham  (Thorn.)  Treat,  of  Consump.  and  Venereal  Diseases.  Lond.  8vo. 

1722.  Marten  (John)  New  theory  of  Consumption.     Lond.  8vo. 

1726.  Barry  (E.,  M.D.)  A  Treat,  on  a  Consumption  of  the  Lungs.     Dub.  8vo. 

1727.  Robinson   (Nich.,  M.D.)  A  new   method   of  treating   Consumptions. — 

Lond.  8vo. 
1727.  Leigh    (Car.)    Phthisiologia  Lancastrensis,   curaccessit    Tentamen,   &c. 

Genev.  4to. 
1733.  Dessault  (P.)  Dissertations  de  Medecine   Sur  la  Phthisie,  &c.    Bord.  12mo. 
1735.  Blackmore  (Sir  R.,  M.D.)  A  Treatise  of  Consumptions,  &c.     Lond.  8vo. 
1752.  Raulin  (Jos.)   Obs.  de  Med.  et  sur  l'usage  du   lait  dans  la  Pulmonie. — 

Par.  12mo. 
1754.  Packe  (Ch.,  M.D.)Explanation  of  Boerhaave's  Aphorisms  on  C.  Lond.  8vo. 
1760.  Stephens  (John,  M.D.)  A  practical  Treatise  on  Consumptions.     Lond.  8vo. 
1764.  Hawkridge  (John)  On  Fevers,  Consumptions,  &c.      York.  8vo. 
1769.  Healde  (Tho.)  Use   of  Oleum   Asphaliti   in   Ulcers   of  the  Lungs,  &c. 

Lond.  8vo. 

1775.  Farr  (S.,  M.D.)  Inquiry  into  the  propriety  of  bloodlet.  in  C.'s     Lond.  8vo. 

1776.  Griffith  (Moses,  M.D.)  Pract.  Obs.  on  Hectic  Fevers  and  Consump.     Lond. 

1777.  Castellani  (L.  P.)  Delia  insussistcnza  del   contagio  tisico.     Mantova.  8vo. 

1778.  Baumes  (J.  B.  T.)  Traite  de  la  Phthisie  pulmonaire.  Montpel.  (Pur.  1805.) 

1779.  Musgrave  (S.,  M.D.)  Gulstonian  Lectures  :  III.  On  the  Pulm.  C.  Lond.  8vo. 

1780.  Simmons  (S.  F.,  M.D.)  Pract.  Obs.  on  the  Treat,  of  Consump.    Lond.  8vo. 

1781.  Deslongeois  (Jeann.)  De  la  pulmonie.     Par.     12mo. 

1782.  Reid  (Th.)  An  essay  on  the  nature  and  cure  of  the  Ph.  Pulm.  Lond.  8vo. 
1784.  Marx  (M.  J.)  Abhandl.  von  d.  Schwindlungensucht.     Hann.    8vo. 
1784.  Raulin  (Jos.)  Traite  de  la  Phthisie  Pulmonaire.     Par.  8vo. 

1787.  Ryan  (M.)    An  Inquiry   into   the   nature,   &c.  of   Cons,  of  the   Lungs. 

Dub.     8vo. 
1787.  Smyth  (J.  C,  M.  D.)  Of  the  effects  of  Swinging  in  Pulm.  Consumption. 

Lond.  8vo. 

1787.  Salvadori  (Matt.)  Del  morbo  tisico.     Trient.  8vo,  2  vols. 

1788.  Charles  (Rich.)  An  Essay  on  the  Treatment  of  Consumption.  Lond.  8vo. 

1789.  Cannella  (B.)     Osservazioni  intorno   le   cagioni,   &c,   della  tisichezza. 

Veron.  4to. 

1791.  Castellani  (L.)  Sulla  pulmonare  tisichezza.     Mantua. 

1792.  May  (W.,M.D.)  Essay  on  Pulmonary  Consumptions.  Plymouth,  1792,  &c. 
1892.  Mossman  (G.,  M.D.)  Essay  on  Scrofula  and  Gland.  Con.  &c.  Bradford.  8vo. 

1792.  White  (W.,  M.  D.)  Obs.  on  the  nature  and  cure  of  the  ph.  pulm.  York.  8vo. 

1793.  Rush  (B.,  M.  D.)  Inquiry  into  the  causes  and  cure  of  C.  Pkilad.  8vo. 
1793.  Beddoes  (Th.,M.D.)  On  a  new  method  of  treating  Consump.  Bristol.  8vo 

1798.  Camck  (A.,  M.  D.)  Diss,  on  the  Bristol  Water,  with  practical   observa- 

tions on  the  prevention  and  treatment  of  Consumption.     Lond.  8vo. 

1799.  Sutton  (Thorn.)  Considerations  regarding  Pulmonary  C.  Lond.  8vo. 
1799.  Id.  Essay  on  the  Causes,  «fec.  of  Pulmonary  Consumption.  Lond.  8vo. 
1801.  Id.  Obs.  on  Med.  and  Dom.  Management  o"f  the  Consumptive.  Lond.  8vo. 

1801.  Pears  (Ch.)  Cases  of  Phthisis  Pulm.  cured  by  Tonics.     Lond.  8vo. 

1802.  Regnault  (J.  B.,  M.  D.)  Obs.  on  Pulm.  C,  or  Essay  on  Lichen  Isl.     Lond 

8vo. 


PHTHISIS    PULMONALIS. 


399 


1803.  Peart  (E.,  M.  D.)  on  Cons,  of  the  Lungs,  with  a  new  mode,  &c.     Lond. 

8vo. 

1804.  Bonnafox-Demalet  (Jul.)  Traite  sur  la  Phthisie  Pulmonale.     Par.  8vo. 

1805.  Busch  (J.  J.)  Untersuch.  ueber  die  natur  der  Lungenschwindsucht.  Duisb. 

8vo. 
1805.  Bourne  (Rob.,  M.D.)  Cases  of  Pulmonary  C.  treated  with  uva  ursi.     Oxf. 
8vo. 

1805.  Lambe  (W.,   M.D.)  Inquiry  into  the  Origin,  &c.  of  Constitutional  Disea- 

ses, particularly  Scrofula,  Consumption,  <&c.     Lond.  8vo. 

1806.  Reid  (John,  M.D.)     A  Treatise  on  the  Origin,  <fcc.  of  Consump.     Lond. 

8vo. 
1808.  Sanders  (Jas.,  M.   D.)  Treatise  on  Pulmonary  Consumption,  with  a  new 

view  of  its  Treatment.     Edin. 
1808.  Brieude  (M.)  Traite  de  la  Phthisie  Pulmonaire.  2  vols.     Par.  8vo. 
1808.  Watt  (Rob.,  M.D.)  Cases  of  Diabetes,  Consumption,  <fec.     Paislty.  8vo. 

1808.  Woolcombe  (W.,    M.D.)  Remarks  on  the  Frequency  and  Fatality  of  dif- 

ferent Diseases,  the  increase  of  Consumption,  &c.     Lond.  8vo. 

1809.  Smyth  (John,  M.  D.)  Facts  and  Obs.  on  Pulm.  Consump.  Uttoxeter.  8vo. 
1809.  Storr  (L.)  Ueber  die  natur  und  heilung  der  Lungenschwinsucht.     Stuttg. 

8vo. 

1809.  Portal  (Ant.)  Observ.  sur  la  Nature  et  le  Traitemeni  de  la  Phthisie.  Paris. 

1810.  Bayle  (G.  L.)  Recherches  sur  la  Phthisie  Pulmonarie.     Par.  8vo. 

1810.  Buxton  (J.,  M.  D.)     An  essay  on  the  use  of  a  regulated  Temperature  in 

Winter  Cough  and  Consumption.     Lond.     8vo. 
1812.  Walther  (J.  A.)  Ueber  das  wesen  der  phthysischen  constitution.  Frank.  8vo. 

1812.  Turton  (W.,  M.  D.)     Observations  on  consumption,  &c.     Lond.     8vo. 

1813.  Duncan  (A.,M.  D.)  Obs.  on  three  different  species  of  Pulm.  Con.  Edin.  8vo. 

1814.  Southey  (H.  H.,  M.  D.)  Obs.  on  pulmonary  consumption.  Lond.  8vo. 
1814.  Sutton  (Thos.,  M.  D.)  Letters  to  the  Duke  of  Kent  on  Consump.  Lond.  8vo. 
1814.  Pears  (C,  M.  D.)  Obs.  on  the  nature  and  treat,  of  consumption.  Lond.  8vo. 

1814.  Herholdt  (J.  D.)     Ueber  die  lungenkrankheiten,  bes.  d.  Lungenschwind- 

sucht.    Numb.     8vo. 

1815.  Young  (Thos.,  M.  D.)  A  Pract.  and  Histor.  Treat,  on  Cons.  Dis.  Lond.  8vo. 
1815.  Gallup  (I.  A.,  M.  D.)  Sketches  of  Diseases,  with  Remarks  on  Pulmonary 

Consumption.     Boston.     8vo. 
1815.  Lambe  (W.,  M.  D.)  Rep.  of  the  effects  of  a  peculiar  Regimen,  &c.   Lond. 
8vo. 

1817.  Tullidge  (H.  H.)  Inquiry  into  the  nature  of  Pulm.  Consump.  Lond.    8vo. 

1818.  Mansford  (J.  G.)  An  inquiry  into  the  influence  of  situation  on  C.  Lond.  8vo. 
1820.  Maygrier.     Diet,  des  Sc.  Med.     (Art.  Phthisie  Pulm.)  t.  42.     Par. 

1823.  Engelhard  (J.  F.)     Die  Lungensucht  in  ihren  verschiedenen  formen  und 

Zeitraumen.     Auran.  8vo. 
1823.  Crichton  (Sir  A.,  M.  D.)  Pract  Obs.  on  the  varieties  of  Pulm.  C.  Lond.  8vo. 
1826.  Louis  (P.C.A.)  Recherches  Anat.  Pathologiques  sur  la  Phthisie.  Par.  8vo. 

1826.  Andral.     Diet,  de  Med.     (Art.  Phthisie.)  t.  16.     Par. 

1827.  Hammersley  (And.,  M.  D.)     A  Diss,  on  the  remote  and  proximate  causes 

of  Phthisis  Pulmonalis.     2nd.  ed.     Nero  York.     12mo. 

1830.  Gannall  (M.)     Two  memoirs  on  the  inhalation  of  Chlorine  in  Consump- 
tion.    Tr.  by  Potter.     Lond.     8vo. 

1830.  Murray  (J.)  Treatise  on  Pulmonary  Consumption.     Lond.     8vo. 

1832.  Blackmore  (E.,  M.  D.)  A  Pract.  Treat,  on  Pulm.  Consumpt.     Lond.  8vo. 

1834.  Clark  (James,  M.  D.)  Cycl.  of  Pract.  Med.     Vol.  4.  Art.  Phthisis. 

1834.  Ramadge  (F.,  M.  D.)     Consumption  Curable,  &c.     Lond.     8vo. 

Transl. 


400  CYSTS    IN    THE    LUNGS. 


CHAPTER  VIII. 

OF    CYSTS    FORMED    IN    THE    LUNGS. 

By  the  term  cyst,  I  understand,  with  most  modern  anatomists,  an 
accidental  membrane,  forming  a  sort  of  shut  sac,  commonly  of  a 
roundish  shape,  but  sometimes  irregular  and  anfractuous,  and 
containing  a  liquid  or  half  liquid  matter,  secreted  by  the  mem- 
brane which  encloses  it.  There  is,  indeed,  another  variety  of 
cysts,  I  mean  those  which  contain  matters  of  a  more  solid  consist- 
ence, and  of  a  kind  not  met  with  in  a  healthy  body,  such  as  the 
matter  of  tubercles,  cancer,  &c. :  but  I  do  not  intend  to  give  any 
account  of  them  at  present.  Cysts  of  the  first  kind  always  con- 
sist of  a  substance  analogous  to  some  of  the  natural  tissues  of  the 
body :  most  commonly  they  resemble,  in  every  respect,  the  se- 
rous membranes,  such  as  the  pleura  and  peritoneum,  as  was  re- 
marked by  Bichat ;  sometimes,  however,  they  are  more  like  the 
mucous  tunics  of  the  bladder  or  intestines.  These  cysts  are  fre- 
quently surrounded  by  a  layer  of  a  fibrous  or  condensed  cellular 
substance,  (of  more  or  less  thickness,  and  commonly  incomplete,) 
by  which  they  are  connected  with  the  neighboring  parts.  Some- 
times we  meet  with  cysts  composed  of  the  two  kinds  of  tissue  just 
mentioned,  with  the  addition,  occasionally,  of  portions  of  carti- 
lage and  even  laminae  of  bone,  of  a  greater  or  less  extent.  The 
inner  surface  of  these  compound  cysts  has  scarcely  ever  the 
smooth  and  polished  surface  of  the  serous  or  mucous  cysts,  being 
uneven,  rough,  and  frequently  coated,  in  different  points,  by  an 
albuminous  or  fibrous  and  half-concrete  substance,  constituting 
one  body  with  the  sac,  and  passing  insensibly  into  it.  Cysts  are, 
of  all  the  kinds  of  accidental  productions,  that  which  is  most 
rarely  met  with  in  the  human  lungs.  Morgagni  gives  only  one 
instance  of  the  sort.  (Epist.  Ixix.  18).  They  are,  however,  by  no 
means  rare  in  the  lungs  of  animals,  particularly  bullocks  and 
sheep ;  and  they  are  usually  of  the  serous  kind,  the  sac  being 
thin,  and  the  contained  liquor  thin  and  very  limpid.  In  the  hu- 
man subject,  on  the  other  hand,  I  have  only  met  with  the  com- 
pound cysts  above  described,  and  this  only  three  or  four  times. 
I  am  disposed  to  believe  that  these  had  formerly  contained  hy- 
datids, (vesicular  worms,)  like  those  to  be  described  in  the  next 
chapter.  The  largest  of  these  cysts  was  situated  in  the  inferior 
lobe  of  the  lungs,  and  might  have  held  an  apple.  It  was  of  a 
very  irregular  shape ;  its  walls  varied  in  thickness  from  two  to 
four  lines,  and  were  lined  internally  by  an  albuminous  or  fibrous 
substance  of  a  yellowish  white  color,  quite  soft  in  some  points, 


HYDATIDS     IN    THL'    LUNGS. 


401 


and  in  appearance  very  like  the  middle  coat  of  an  artery.  To- 
wards its  surface,  this  cyst  had  a  perfectly  fibrous  appearance, 
like  tendon  ;  and  in  different  points  it  had  the  look  and  the  con- 
sistence of  cartilage.  There  were  also  several  bony  plates  in  it, 
some  of  which  were  parallel,  and.  others  quite  perpendicular  to 
the  walls,  and  prolonged  on  either  side,  so  as  to  project  at  once 
into  the  cavity  of  the  cyst  and  into  the  pulmonary  substance, 
with  which  latter  they  were  firmly  united  by  means  of  a  thick 
layer  of  a  fibrous  substance.  This  sheath  invested  them  while 
contained  in  the  walls  of  the  cyst,  but  left  them  to  project  quite 
nuked  into  its  interior,  which  contained  a  yellowish  puriform 
fluid.  It  cannot  be  doubted,  that  a  cyst  of  this  size  must  have 
occasioned  a  diminution  or  total  loss  of  the  sound  of  respiration 
in  the  corresponding  points  of  the  chest.* 


CHAPTER  IX. 

OF    VESICULAR    WORMS,    OR    HYDATIDS    IN    THE    LUNGS. 

The  only  species  of  vesicular  worms  that  I  have  met  with  in 
the  lungs,  belongs  to  the  genus  to  which  I  have  given  the  name 
of  Acephalocyst.f  These  animals,  formerly  named  hydatids, 
and  long  confounded  with  cysts,  properly  so  called,  have  the 
form  of  simple  vesicles  of  a  spheroid  or  ovoid  shape,  very  variable 
in  size,  soft,  and  of  a  degree  of  consistence  and  an  appearance 
exactly  like  that  of  half-boiled  white  of  egg.  Their  coats  are 
diaphanous,  or  semi-transparent,  colorless,  or  of  a  milky  color, 
varying  sometimes  towards  reddish,  yellowish,  greenish,  or 
greyish.  Sometimes  they  are  of  unequal  thickness ;  but  fre- 
quently they  are  uniform  in  this  respect.  These  vesicles  con- 
tain more  or  less  of  a  fluid  which  is  commonly  serous  and  limpid, 
sometimes  turbid,  and  tinged  of  a  yellowish  or  sanguine  hue. 
Sometimes  a  large  vesicle  includes  several  smaller  ones ;  at  other 
times,  still  smaller  ones  are  found  adherent  to  the  internal  or  ex- 

*  For  further  details  respecting  the  organic  lesions  described  in  this  chapter,  I 
refer  the  reader  to  Bichat's  Anatomie  General?,  par  Beclard,  Paris,  1821,  t.  i.  p. 
198,  t.  i\.  p.  151.  158;  Cruveilbier's  Anat&mie  Patkologique ;  Abernethy's 
Surgical  Observations  on  Tumors,  p.  107  ;  Diet.  de  Medicine,  t.  xii.  p.  525.  For 
some  observations  on  the  origin  and  mode  of  development  of  these  cysts,  I 
refer  to  an  article  by  Louis  in  the  Encyclopedic  Methodique,  to  the  work  of  Bi- 
,  dai  iusl  quoted,  and  to  an  article  by  8ir  Astley  Cooper  in  the  second  part  of  his 
ami  Sir.  Travers's  Essays,  p.  222.  For  an  account  of  the  difference  between 
simple  cysts  and  hydatid  cysts,  see  Beclard's  additions  to  Bichat,  t.  iv.  p.  460.— 
Trans! . 

t  In  the  Memoirs  of  the  Faculty  of  Medicine  printed  in  1806,  but  not  yet  pub- 
lished     See  an  extract  from  this  in  the  Bulletin  of  the  Facultv,  No.  10,  1804. 
51 


40*2  HYDATIDS    IN    THE    LUNGS. 

ternal  surface  of  their  parent,  from  which  they  only  appear  to  be 
separated  when  they  have  attained  a  certain  size.  Acephalocysts 
present  no  distinguishable  organ,  and  offer  the  simplest  example 
of  an  animal  that  can  be  imagined.  This  extreme  simplicity  of 
conformation  has  induced  Rudolphi  to  call  in  question  their  ani- 
mal character.*  In  this  place  I  shall  merely  observe,  that  M. 
Percy  has  seen  this  species  of  hydatids  move  in  a  very  distinct 
manner,  and  I  have  myself  observed  all  the  stages  of  their  re- 
production. This  takes  place,  as  in  certain  polypi,  by  a  process 
somewhat  like  budding.  Small  buds  form  in  the  substance  of 
the  coats  of  the  animacule,  which  project,  either  exteriorly  or 
interiorly,  grow  hollow,  assume  the  rounded  form  as  they  en- 
large, and  finally  detach  themselves  from  their  parent.  Acepha- 
locysts are  always  inclosed  in  a  cyst,  which  completely  separates 
them  from  the  surrounding  parts.  These  cysts  are  commonly  of 
a  fibrous  nature,  but  frequently  there  are  found  in  them  portions 
of  a  cartilaginous  or  bony  character.  Their  internal  surface  is 
rarely  smooth :  frequently  it  is  so  unequal  as  to  have  the  appear- 
ance of  being  lacerated.  Sometimes  it  is  lined  by  an  opaque 
albuminous  matter,  semi-concrete,  and  partially  reduced  to  de- 
tritus, and  of  a  yellow  ochrey  or  tawny  color.  When  there  are 
several  hydatids  in  one  cyst,  this  further  contains  a  fluid  in  which 
they  float,  which  is  sometimes  limpid,  sometimes  turbid,  yel- 
lowish, or  sanguinolent.  When  the  cyst  contains  only  one 
hydatid,  this  sometimes  fills  it  completely,  and  lines,  as  it  were, 
its  internal  parietes.  This  species  of  Acephalocysts  may  origi- 
nate in  almost  every  organ  in  the  body.  They  have  been  often 
met  with  in  the  lungs  ;  at.  least,  all  the  cases  of  hydatids  recorded 
as  being  found  in  this  viscus,  appear  to  me  to  belong  to  this 
species.  The  most  remarkable  are  those  published  by  Johnson ,f 
Collet,J  Maloet,^  Beaumes,||  and  Geoffroy.1I  I  shall  here  give 
an  abridgment  of  the  case  of  M.  GeofTroy,  because,  I  think  it 
must  appear  evident  that,  by  means  of  the  stethoscope,  the  prog- 
ress of  the  disease  might  have  been  easily  followed,  and  perhaps 
even  a  diagnosis  sufficiently  precise  might  have  been  attained  to 
justify  the  puncture  of  the  chest.** 

*  Entozoorum,sive  Verm.  Intest.  Hist.  Nat.  Amstcl.  1810,  vol.  ii.  pars.  ii.  p.  367. 

t  Philos.  Trans.  Abridg.  +  Comment,  dereb.  in  fecient.  nat.  vol.  xiv. 

§  Mem.  de  l'Acad.  des  Scienc.  an.  1762.  |]  Annales  de  Montpel.  torn.  i. 

IT  Bulletin  de  l'Ecole  do  Med.  an.  1805. 

Many  cases  of  hydatids  discharged  by  expectoration  are  on  record,  and  still 
more  in  which  they  were  found  in  the  lungs  after  death.  Of  the  former  kind 
see  a  case  by  Dr.  Collet  in  the  Med.  Trans,  of  the  Coll.  of  Phys.  vol.  ii.  p.  486  : 
another  in  the  Loral.  Med.  Journ.  vol.  vi.  p.  293,  1785  ;  and  two  others  in  An- 
dral's  Clin.  Med.  t.  iii.  p.  393,  in  which  place  there  arc  also  four  other  interesting 
cases  of  pulmonary  hydatids.  For  further  accounts  of  Hydatids,  see  Dr.  Hun- 
ter's paper  in  the  Med.  and  Chir.  Trans,  vol.  i.  p.  34  ;  Baillie's  Morbid  Ana*,  p. 
237;  and  Parr's  Med.  Diet.  vol.  i.  p.  765—  Transl. 


HYDATIDS    IN    THE    LUNGS. 


403 


A  young  man  had  an  attack  of  pneumonia  when  eighteen 
years  of  age,  which  was  perfectly  cured,  and  he  remained  well 
two  years;  he  then  caught  a  violent  cold,  which  was  attended 
by  acute  pain  in  the  left  side  which  prevented  him  lying  on  it. 
He  never  got  well  of  this  last  symptom.  He  was  afterwards 
attacked  with  jaundice  which  lasted  three  months,  and  he  also 
passed  some  portions  of  taenia.  The  cough  and  pain  of  side  re- 
turned after  this,  very  violently,  and  upon  their  cessation,  he 
discovered  a  small  movable  tumor  situate  in  the  right  hypo- 
chondre.  This  tumor  increased  and  extended  towards  the 
umbilicus,  being  attended  by  cholic  and  headache.  The  pulsa- 
tion of  the  heart  was  very  strong  in  the  epigastric  region.  The 
principal  symptoms  at  the  end  of  three  years  were  constant 
dyspnoea,  which  increased  to  a  feeling  of  suffocation  on  going  up 
stairs  ;  frequent  faintings  ;  occasional  cough  and  spitting  of 
blood,  and  constant  tremblings.  After  a  year  and  a  half  these 
symptoms  increased,  and  the  fits  of  suffocation  became  more 
violent.  In  one  of  these  he  suddenly  expired.  On  examination 
after  death,  a  large  hydatid  was  found,  partly  contained  in  the 
liver,  and  partly  projecting  into  the  abdomen.  Its  coats  were  thin 
yet  fibrous.  It  contained  a  fluid  of  a  brown  color,  and  a  great 
number  of  smaller  hydatids  ;  most  of  them  of  the  size  of  peas  ;  one 
or  two  as  large  as  the  yolk  of  an  egg.  The  lower  end  of  the  sac 
adhered  to  the  small  curvature  of  the  stomach.  In  the  chest  there 
was  found  on  each  side  an  enormous  hydatid  containing  five  pints 
of  fluid.  They  adhered  to  the  ribs  and  the  mediastinum,  and  by 
their  increase  had  compressed  the  lungs  into  a  thin  layer  on  the 
anterior  part  of  the  cavity.  The  heart  was  completely  thrust  out 
of  the  thorax  into  the  epigastrium.  Each  hydatid  was  eleven  in- 
ches long,  and  contained  full  five  pints  of  a  perfectly  limpid  fluid. 
It  is  difficult  to  learn,  from  the  description  of  these  hydatids, 
whether  they  originated  in  the  substance  of  the  lungs,  or  merely 
beneath  the  pleura  pulmonalis  or  costalis.  I  think  it,  however, 
most  probable,  that  they  originated  in  the  substance  of  the  lungs. 
M.  Cayol  has  since  presented  a  case  very  similar  to  the  above, 
which  has  not  yet  been  made  public.  In  the  Journal  de  Med. 
for  1801,  there  is  the  case  of  a  man  who  expectorated  for  several 
months  rounded  pellicles  which  were  evidently  the  remains  of 
hydatids,  and  some  seemed  to  be  these  merely  flattened.  I  have 
myself  seen  two  similar  cases,  both  of  which,  as  well  as  that  re- 
corded in  the  Journ.  de  Med.  were  cured.  On  this  account,  the 
actual  seat  of  these  bodies  could  not  be  determined,  but  there 
can  be  little  doubt  of  its  having  been  the  lungs.  About  fifteen 
years  ago,  a  young  woman  consulted  me  on  account  of  being 
affected  with  severe  dyspnoea,  cough,  abundant  expectoration 
and  emaciation, — in  short,  all  the  ordinary  symptoms  of  phthisis 


404  HYDATIDS    IN    THE    LUNSSi 

pulmonalis.  One  day,  after  acute  pain  of  the  epigastrium,  she 
evacuated  by  stool  a  considerable  quantity  of  hydatids,  of  a  size 
from  that  of  a  filbert  to  that  of  a  pigeon's  egg.  From  this  very 
day  the  hectic  fever,  the  catarrhal  symptoms,  and  dyspnoea 
ceased,  and  shortly  after  the  patient  regained  her  flesh  and 
strength.  May  we  believe  in  this  case,  that  a  cyst  situated  in 
the  left  lung  made  a  passage  into  the  stomach  or  colon  through 
the  diaphragm  ?  Be  this  as  it  may,  there  can  be  no  doubt,  I 
think,  that  in  all  such  cases  the  stethoscope  would  enable  us  to 
come  to  a  much  more  accurate  diagnosis  than  we  could  attain 
without  it.  The  site  of  the  disease  and  its  extent,  would,  at 
least  be  easily  ascertained.  In  1821,  Dr.  Beaugendre  of  Quim- 
perle  afforded  me  an  opportunity  of  examining  the  chest  of  a 
woman,  recovering  from  a  pectoral  affection,  during  the  contin- 
uance of  which  she  had  expectorated  a  great  number  of  acepha- 
locysts.  There  still  remained  some  cavernous  rhonchus  in  the 
site  of  the  cyst,  and  Dr.  Beaugendre  had  several  times  heard,  in 
the  same  place,  a  slight  guggling  independent  of  the  respiratory 
movements,  and  which  seemed  owing  to  the  automatic  contraction 
of  the  hydatids.* 

Treatment. — The  signs  of  a  vast  hydatid  cyst  seated  near 
the  surface  of  the  lungs  or  beneath  the  costal  pleura,  being 
the  same  as  those  of  empyema,  would  point  out  the  propriety 
of  the  operation  used  in  this  disease ;  and  perhaps  such  an 
operation  might  be  more  successful  in  the  case  of  the  hydatid 
than  in  that  of  the  empyema.  When  the  expectoration  of  hy- 
datids or  other  signs  point  out  their  existence  in  the  lungs, 
common  salt  would  appear  most  deserving  a  trial  as  a  means 
of  cure.  The  rot  and  the  staggers  in  sheep,  are  occasioned 
by  the  development  of  two  species  of  vesicular  worms  (the  cys- 
ticercus  lineatus  and  tenuicollis,  and  the  cccnurus  cerebralis,  of 
Rudolphi,)  the  one  in  the  liver  or  some  other  of  the  abdominal 
viscera,  and  the  other  in  the  ventricles  of  the  brain.  The  sheep 
which  feed  in  salt  meadows  are  exempt  from  this  disorder,  and  a 
removal  to  such  meadows  most  frequently  cures  those  already 
affected    with  it.     I  have  more   than  once  employed   salt  water 

*  MM.  Briancon  and  Piorrv  appear  to  have  observed  tin-  same  sounds  in  hy- 
datid tumors  of  the  abdomen,  where,  of  course,  there  could  be  no  mistake  as 
to  the  respiratory  murmur.  Combined  with  this,  there  was  found  also,  on  per- 
cussion, a  dull  sound  having  something  of  an  oscillator;  character,  and  the  two 
phenomena  together,  they  conceived  to  be  indicative  of  the  presence  of  acepha- 
locysts.  (Piorry,  De  la  Percussion  M6d.  p.  158.)  Dr.  Ambroise  Laennec  has 
also  observed,  in  a  case  of  abdominal  tumor  with  all  the  characters  of  an  ova- 
rian dropsy,  expansive  and  contractile  motions  bearing  no  relation  to  the  beat  of 
the  pulse,  and  which  was.  probably,  owing  to  the  automatic  movements  of  an 
acephalocyst.  (Rev.  Med.  Oct.  1828).  These  observations,  however,  although 
valuable  in  relation  to  the  diagnosis  of  abdominal  hydatids,  air  of  no  u>.  in  Hi, 
case  of  pulmonary  hydatids,  the  only  certain  sign  of  winch  is  that  supplied  l.\ 
the  expectoration. — (M.  L.) 


CONCRETIONS    IN    THE    LUNGS. 


405 


baths,  with  seeming  success,  in  cases  of  individuals  affected  with 
a  disease  of  this  kind.  It  is  not  necessary  that  the  hydatids 
should  be  expelled  to  effect  a  cure  :  it  suffices  that  these  are  de- 
prived of  their  vitality.  In  this  case,  the  liquid  which  they  con- 
tain, and  also  that  in  which  they  are  contained,  is  absorbed ;  the 
cyst  contracts  into  a  very  small  compass  ;  and  upon  cutting  into 
the  tumors,  we  find  the  hydatids  quite  flattened,  closely  pressed 
together,  and  sometimes  stratified  with  layers  of  the  albuminous 
and  friable  matter  which  I  mentioned  above  in  describing  them.* 
In  this  state  such  tumors  appear  to  exert  no  bad  influence  on 
the  system  ;  and  no  doubt,  cases  of  this  kind  have  been  mistaken 
for  cancerous  swellings,  which  in  rare  instances,  have  got  well 
beyond  all  expectation. 


CHAPTER  X. 

OF    BODIES    OF    A    CARTILAGINOUS,    BONY,    CALCULOUS    AND 
CHALKY    NATURE,    FORMED    IN    THE    LUNGS. 

These  various  productions  are  frequently  met  with  in  the  lungs, 
and  they  have,  indeed,  been  noticed  by  almost  every  pathological 
anatomist  since  the  sixteenth  century.  Besides  the  cartilaginous 
productions  already  described  in  former  parts  of  this  work,  we 
sometimes  find  in  the  lungs  cartilaginous  cysts  inclosing  bony  or 
chalky  concretions,  of  the  kind  immediately  to  be  described ;  and 
also  cartilages  of  no  regular  shape  or  size,  containing  here  and 
there  points  of  incipient  ossification.  The  bone  which  is  formed 
in  these  cartilaginous  bodies,  or  without  their  previous  presence, 
in  the  substance  of  the  lung,  is  never  of  a  perfect  kind  ;  or,  at  least 
I  have  never  met  with  any*  accidental  production  of  this  kind  in 
the  lungs  which  had  either  the  fibrous  texture  or  solidity  of  the 
middle  of  the  long  bones,  or  the  spongy  character  of  the  ends  of 
the  same  bones.f     It  appears  that,  in  their  formation,  a  greater 

*  In  a  former  note  I  had  occasion  to  refer  to  the  opinion  of  Dr.  Baron  respect- 
ing the  supposed  origin  of  pulmonary  tubercles  in  hydatids,  and  to  state  my  be- 
lief  of  the  untenable  grounds  on  which  his  opinion  is  founded.  It  seems  proba- 
ble, as  stated  by  Dr.  M.  Laennec,  that  the  mistake  of  Dr.  B.  may  be  attributed 
parti]  to  his  having  mistaken  for  tubercles,  examples  of  that  degeneration  of  hy- 
datids, described  by  our  author  in  the  text,  as  resulting  from  the  death  of  these 
animals;  and  partly  to  his  having  overlooked  tho'distinctive  characters  of  the  dif- 
ferent species  of  hydatids  described  by  naturalists,  and  thereby  confounded  the 
cysticercus  finna  of  the  hog  (which  is  of  a  comparatively  solid  character,  and  has 

verv  rarely  1 1  met  with  in  the  human  body,  and  never  in  the  lungs.)  with  the 

simple  acephalocyst  See  the  work  ofRudolphi.  See  also  a  review  of  Dr.  Ba- 
ron's work,  by  Dr.  Meriadee  Laennec,  in  the  Revui  Med.  for  April.  1825. —  Tremal. 

t   This  remark  is  applicable  not  only  to  the  accidental  osseous  ti^ne  developed 


406  CONCRETIONS    IN   THE    LUNGS. 

quantity  of  calcareous  phosphate,  and  a  much  less  proportion  of 
gelatine  is  employed,  than  in  true  bone ;  hence  these  bodies  re- 
semble more  a  piece  of  stone  than  bone, — a  character  which  ac- 
counts for  the  epithets  calculous  and  tophaceous  given  to  them 
by  authors.  In  some  cases  they  do  not  contain  a  particle  of  gela- 
tine ;  and,  in  this  case,rthe  calcareous  phosphate  resembles  moist- 
ened chalk*  I  shall  notice  these  different  varieties  under  the 
name  of  imperfect  ossifications,  and  chalky  concretions. 

The  imperfect  ossifications  are  encysted,  or  not  encysted.  The 
former  are  very  rare  in  the  lungs.  They  are  of  a  rounded  form, 
of  a  size  from  that  of  a  hemp-seed  to  that  of  a  hazel-nut,  and  are 
enclosed  in  a  cartilaginous  cyst,  of  half  a  line  to  a  line  in  thick- 
ness, which  adheres  closely  to  them.  The  non-encysted  ossifi- 
cations are  of  a  very  irregular  shape.  Their  surface  is  rugged 
and  rough.  Interiorly  they  are  white,  opaque,  very  similar  to 
calculous  productions,  and  readily  reduced  to  powder  by  being 
bruised.  On  the  other  hand,  their  external  parts  are  somewhat 
yellowish,  slightly  diaphanous,  more  difficultly  pulverizable,  and, 
in  short,  in  a  more  perfect  state  of  ossification.  These  ossifi- 
cations are  found  sometimes  included  in,  and  intimately  adhe- 

in  the  lung,  but  to  that  which  forms  elsewhere.  In  fact,  I  do  not  know  that  it 
has  been  observed  that  morbid  ossifications  ever  have  the  texture  of  real  bones  ; 
the  mere  resemblance  in  chemical  properties  is  an  imperfect  one.  The  con- 
formation is  never  the  same  :  they  are  either  granulations  or  foliations,  or  a 
sort  of  membranes,  or  amorphous  masses,  which  no  way  resemble  either  long, 
short,  or  flat  bones. — Andrnl . 

*  The  calcareous  concretions  found  in  the  lungs  contain  not  only  phosphate 
of  lime  united  with  a  variable  quantity  of  animal  matter,  but  other  elements,  as 
appears  from  the  following  analysis  made  by  Dr.  Sgazzi  of  Bologna  :— 

Phosphate  of  lime 156 

Carbonate  of  lime 0.39 

"  "     magnesia       .     .     .     0.06 

f  Composed  of 

Fatty  matter  sui  generis,  soluble 

in  ether,  insoluble  in  alcohol       0.06 

.    .      ,  „„.     Cholesterine 0.66 

Animal  matter °-84<j  Mucus 0.09 

Yellowish  brown  substance  not 
characterized,  analogous  to  mu- 
cus, or  imperfect  albumen       .     0.03 

Oxide  of  iron 0.00 

Silex 0.03 

Loss 0.03 

In  all  osseous  concretions  in  the  human  body,  the  composition  is  found  to  be 
analogous  as  to  the  presence  of  phosphates  and  carbonates  of  lime,  except  in  the 
concretions  which  form  around  and  within  the  articulations  of  gout]  persons. 
These  form  a  class  by  themselves,  and  arc  composed  of  the  urate  of  soda,  a 
very  remarkable  circumstance,  which  shows  a  peculiar  connexion  between  the 
gout  and  gravel  ;  it  is  known,  in  fact,  that  in  a  vast  majority  of  cases,  the  calculi 
are  formed  of  uric  acid.  I  will  add,  that  in  the  gout,  the  deposits  of  uric  acid 
are  found  not  only  round  the  affected  articulations,  but  I  have  met  with  them 
also  in  the  cellular  tissue  of  the  limbs,  either  deep  or  immediately  under  the 
skin  ;  in  the  thick  part  of  the  ear,  and  even  in  the  spongy  extremities  of  the 
long  bones,  and  all  this  in  the  same  individual. — findral. 


CONCRETIONS    IN    THE    LUNGS. 


407 


rent  to,  the  pulmonary  tissue ;  at  other  times  they  are  observed  in 
the  centre  of  a  cartilaginous  production ;  and  frequently  in  the 
body  of  a  tubercle,  especially  those  of  the  bronchial  glands.     In 
the  latter  case,  when  the  tubercle  softens,  the  bony  concretion 
may  be  found  loose  in  the  cavity,  or  may  be  expectorated,  if  it  is 
not  of  too  great  a  size  to  pass  through  the  bronchi.     The  chalky 
concretions    are    found   in   two    states, — one   resembling    chalk 
slightly  moistened,   the  other  like  chalk   completely  softened   in 
water.     In  the  last  state  they  are  always  encysted ;  in  the  first 
they  may,  or  may  not  be,  although  they  most  commonly  are  so. 
When  crushed  between  the  finger  and  thumb,  they  are  sometimes 
reducible  to  an   impalpable   powder,   but  frequently  they  give  the 
feeling  as  if  grains  of  sand  were  intermixed  with  the  soft  chalk ; 
these  grains  are  small  ossified  points.     The  cysts  enclosing  these 
cretaceous  productions  are  commonly  cartilaginous.      They  are 
rounded,  or  without  any  regular  figure.     I  have  seen  one  in  the 
form'  of  a  pyramid  with  four  unequal  sides.     The  rounded  cysts 
are  sometimes  bony,  but  of  an  imperfect  ossification,  and  resem- 
bling, in   all  respecls,  the   semi-transparent  external  crust  of  the 
osseo-calcareous  concretions  described  above.     I  have  sometimes 
found  concretions  of  this  sort  composed  of  several  bony  or  car- 
tilaginous cysts,  one  included  within  the  other,  and  each  separated 
by  a  layer  of  soft  cretaceous  matter.     It  is   much  more  common 
to  find  this  half-fluid  chalky  matter  in  the   centre  of  a  tubercle, 
particularly  in  the  bronchial  glands.     In  this  case,  although  the 
matter  is  equally  soft  as  the  substance  of  the  tubercle  itself,  still 
it  is  easily  distinguished  from  it,  by  its  greater  opacity,  and  by  its 
whiteness,  which  form  a  considerable  contrast  with   the  pale  yel- 
low color,  of  the   tuberculous  matter.     When  allowed  to   dry, 
this  cretaceous  matter  becomes  white,  and  acquires  a  degree  of 
cohesion  which   prevents  it  from  being  pulverized  by  the   mere 
pressure  of  the  finger.    The  bony  or  cretaceous  concretions  of  the 
lungs  are  commonly  very  small ;  I  have  never  seen  them  larger 
than  an  almond.     Neither  have  I  ever  seen  a  complete  conversion 
of  a  portion  of  lung  into  a  substance  of  this  sort,  but  sometimes  I 
have  observed  the  pulmonary  tissue  around  an  imperfect  cicatri- 
zation, as  if  injected,  or  impregnated  with  a  small  quantity  of  dis- 
seminated chalky  matter.* 

*  I  have  not  seen  any  more  than  Laennec,  any  large  portion  of  the  lung 
transformed  into  calcareous  matter  ;  and  there  is  reason  to  think  that  the  degen- 
erations of  this  nature,  described  by  old  writers,  never  existed,  but  that  they 
belong  to  those  common  cases  where  the  false  membranes,  having  become  carti- 
laginous or  osseous,  envelop  the  lung  more  or  less  'completely,  separate  it 
In. in  the  rilis  and  hide  it  at  first  from  sight. 

I  knew  a  case  where  an  altogether  peculiar  ossiform  transformation  existed 
in  the  lungs;  it  was  seated  in  the  coats  of  the  bronchi,  which  from  their  third 
or  fourth  divisions  to  their  minutest  ramifications,  represented  inflexible  canals 
whose  coats  were  entirely  bone.  I  found  this  the  case  in  an  old  man  of  eighty, 
who  died  at  the  Bicetre  Hospital. — Andral. 


408  CONCRETIONS  IN  THE  LUNGS. 

Very  singular  opinions  as  to  the  cause  and  origin  of  these  cal- 
careous productions  are  to  be  found  in  the  writings  of  most  patho- 
logists. Cullen,  with  many  others,  regards  them  as  a  frequent 
cause  of  asthma,  and  thinks  that  they  may  be  occasioned  by  the 
powdery  substances  diffused  through  the  air  breathed  by  different 
kinds  of  artisans^ — such,  for  instance,  as  starch-makers,  lapidaries, 
lime-burners,  Stc.  The  chemical  nature  of  the  concretions,  so 
much  better  known  than  formerly,  renders  this  opinion  quite  un- 
tenable at  the  present  day.  I  do  not  mean  to  deny  that  the  habi- 
tual respiration  of  a  powdery  atmosphere  may  cause  a  temporary 
dyspnoea,  and  even  be  a  source  of  a  formal  disease  of  the  lungs ; 
but  as  a  proof  that  too  much  stress  has  been  laid  on  this  circum- 
stance as  a  cause  of  pulmonary  diseases,  we  have  only  to  examine 
the  expectoration  of  a  person  who  has  passed  the  night  in  an 
apartment,  the  air  of  which  has  been  rendered  turbid  by  the  smoke 
of  a  lamp,  or  of  a  carrier  who  has  been  all  day  on  a  road  enve- 
loped in  clouds  of  dust : — in  either  case,  we  shall  find  that,  in  the 
course  of  four-and-twenty  hours,  the  whole  of  the  extraneous 
matter  has  been  expelled  along  with  the  bronchial  mucus.*  Be- 
sides, if  such  substances  could  be  retained  in  the  lungs,  they  would 
be  retained  in  the  bronchi,  and  we  should,  in  such  a  case,  find 
there  an  accumulation  of  such  matters,  differing  in  their  nature 
according  to  the  particular  kind  of  occupation  of  the  individual. 
Now,  I  believe,  nothing  of  this  kind  has  ever  been  discovered  on 
dissection  ;  at  least,  I  can  assert  that  I  have  never  met  with  any 
thing  of  the  sort,  though  I  have  examined  the  lungs  of  a  great 
number  of  persons  who  had  passed  their  lives  in  workshops  of 
which  the  atmosphere  was  constantly  charged  with  calcareous  or 
other  kinds  of  dust.  Furthermore,  I  do  not  intend  denying  that 
the  existence  of  a  great  number  of  bony  concretions  in  the  lungs 
may  be  productive  of  habitual  dyspnoea,  more  or  less  severe  ;  but  I 
can  assert  that  I  have  met  with  such  concretion,  and  in  great  quan- 
tity, in  the  lungs  of  persons  who  had  never  experienced  any  affec- 
tion of  the  respiration  ;  and  I  am  convinced,  as  well  by  my  own 
dissections,  as  by  those  given  by  other  observers,  that  such  con- 
cretions have  never  been  found  sufficiently  voluminous,  nume- 
rous, or  congregated,  to  justify  our  attributing  to  them  any  case 
of  dyspnoea  so  intense  as  to  be  reckoned  by  practitioners  under 
the  head  of  asthma.  The  opinions  of  M.  Bayle  respecting  the 
effect  of  these  concretions  are  very  singular,  quite  unsupported 
by  either    reasoning  or  analogy,  and,    indeed,  rather    invalidated 

It  is  hardly  necessary  to  observe,  that  the  argument  in  the  text,  however 
good  against  the  origin  of  earthy  concretions  in  the  lungs,  is  altogether  invalid 
as  regards  the  production  of  other  diseases  of  the  pulmonary  or  bronchial  sys- 
tems. Indeed,,  as  was  stated  in  a  former  note,  no  fact  is  better  established  than 
the  power  of  a  powdery  atmosphere  to  cause,  directly,  pulmonary  disea 
Transl. 


CONCRETIOiNS    IN    THE    LUNGS. 


409 


than  confirmed  by  the  facts  he  lias  himself  adduced.  He  consi- 
ders them  as  one  cause  of  phthisis,  and  gives  the  following  state- 
ment of  the  symptoms  produced  by  them :  "  The  majority  of 
subjects,  (he  says)  affected  with  this  disease,  expectorate  small 
calcareous  fragments,  of  a  greyish  or  whitish  color,  often  in 
great  number,  and  they  have  a  dry  cough  for  a  long  period."* 
It  is  remarkable  that  M.  Bayle  mentions  neither  expectoration, 
dyspnoea,  wasting,  nor  hectic  fever,  as  symptoms  of  the  com- 
plaint, and  it  is  therefore  singular  how  he  has  been  led  to  reckon 
it  as  a  species  of  consumption.  The  two  examples  adduced  by 
him  are  very  little  to  the  purpose.  The  first  (Case  XXIII.) 
is  the  case  of  a  man  affected  for  nine  months  with  a  slimy  expec- 
toration, intermixed  with  puriform  sputa,  and  occasionally  with 
small  chalky  fragments.  Hectic  fever  supervened  and  carried 
him  oft'  in  six  weeks.  A  great  number  of  small  cretaceous  con- 
cretions, some  soft,  some  hard,  some  encysted,  some  not  encysted, 
were  found  in  the  lungs.  The  substance  of  the  lungs  was 
slightly  indurated  around  these  concretions,  but,  in  other  re- 
spects, healthy.  In  this  instance  it  is  evident  that  the  consump- 
tion and  death  were  produced  by  a  chronic  catarrh ;  and  I  see 
no  reason  to  attribute  the  result  to  the  concretions,  since  we  often 
find  them  equally  numerous  without  any  such  consequence.  The 
second  example  (Case  XXXIV.)  is  that  of  a  man  who  died  of 
fever  complicated  by  pleuro-pneumonia.  He  had  experienced, 
for  twelve  months,  dyspnoea,  frequent  cough,  and  consequent 
mucous  expectoration,  but  very  little  emaciated.  In  this,  as 
well  as  the  former  case,  we  find  nothing  characteristic  of  true 
consumption.  In  examining  the  cases  of  pulmonary  concretions 
of  this  kind,  contained  in  the  writings  of  Morgagni,  Bonetus, 
and  various  other  authors,  it  is  easy  to  perceive  that,  in  most  of 
them,  the  existence  of  these  was  productive  of  no  severe  symp- 
tom, and  that  even  the  dry  cough,  or  cough  with  ropy  expectora- 
tion,— symptoms,  be  it  remembered,  of  very  uncertain  import, — 
was  by  no  means  a  constant  attendant  on  such  a  condition  of  parts. 
My  own  dissections  afford  a  similar  result.  I  have  often  found 
concretions  of  this  kind  in  persons  who  had  no  disorder  of  the 
respiration.  Others  had  a  dry  cough,  or  cough  with  expectora- 
tion of  different  kinds,  and  with  or  without  dyspnoea;  but  there 
was,  in  almost  all  these,  some  other  morbid  alteration  of  the  pul- 
monary tissue,  to  which  the  symptoms  might  be  attributed  with  as 
much  justice  as  to  the  concretions,  or  more  so.  In  particular,  it 
is  very  common  to  find  co-existing  with  these  concretions,  traces 
of  cicatrizations  in  the  lungs,  of  the  kind  described  in  a  former 
chapter ;  and,   at  the  same  time,  to  observe  the   pulmonary  tis- 

*  Rechcrclies  sui  la  Phthisie,  p.  34. 

52 


410  CONCRETIONS  IN  THE  LUNGS. 

sue  flaccid,  hard,  and  impregnated  with  a  great  quantity  of 
black  pulmonary  matter  around  the  concretions,  and  the  inter- 
stices that  separate  [them  from  the  cellular,  fibrous,  or  cartilagi- 
nous cicatrices  alluded  to.  From  these  facts  I  am  led  to  be- 
lieve, that,  in  most  cases,  these  concretions  are  consequent  to  tu- 
berculous affections  that  have  been  cured,  and  are  the  product 
of  the  curative  efforts  of  nature,  which  appear  to  have  elaborated 
a  superabundance  of  the  calcareous  phosphate :  this  seems  ne- 
cessary' to  the  formation  of  the  cartilaginous  bodies  which  con- 
stitute, for  the  most  part,  the  fistulse  and  cicatrices  found  in  such 
cases  in  the  lungs.  Several  of  the  cases  related  (XIX.  and 
XXII.)  countenance  this  opinion,  and  others  to  the  same  purport 
will  be  given  afterwards.*  I  by  no  means,  however,  wish  to  as- 
sert that  concretions  of  this  kind  may  not  take  place  in  the  lungs 
primarily,  and  independently  of  the  previous  existence  of  tuber- 
cles ;  but  I  look  upon  such  cases  as  very  rare  ;  and,  when  they 
do  occur,  I  am  assured  that  they  give  rise  to  little  or  no  disorder 
of  the  system.f 

The  bony  and  chalky  concretions  of  the  lungs  being  always  of 
small  size,  their  existence  can  never  be  ascertained  nor  even  sus- 
pected by  the  aid  of  the  stethoscope,  unless  they  are  situated  in  a 

*  I  have  also  published  fn  my  Clinique  Medicale  some  facts  which  entirely  cor- 
roborate the  opinion  of  Laennec.  One  of  these,  for  example,  relates  to  the 
case  of  an  individual  who,  after  having  exhibited  some  years  before  his  death, 
all  the  rational  symptoms  of  pulmonary  phthisis,  recovered.  On  opening  the 
body,  no  tubercles  were  found  in  the  lungs,  but  in  their  stead  were  cutaceous 
concretions  towards  the  upper  parts  of  these  organs.  This  and  many  other 
facts  in  which  I  have  been  able  to  discover  the  transformation  of  tubercles  into 
calcareous  matter,  have  led  me  to  suggest  as  a  possible  means  of  curing  tuber- 
cles in  the  lungs,  the  transformation  of  the  tuberculous  matter  to  a  calcareous 
state.  In  this  manner  pulmonary  phthisis,  using  the  expression  in  the  sense 
given  to  it  by  Laennec,  may  terminate.favorably  in  three  different  ways  :  by  the 
absorption  of  the  tuberculous  matter,  by  the  transformation  of  this  matter  into 
calcareous  substance,  or  by  the  cicatrization  of  the  cavities. 

The  first  mode  is  as  yet  only  probable,  the  other  two  seem  to  me  demonstrated . 
Jlndral.  » 

t  The  cases  in  which  calcareous  concretions' are  found  in  the  lungs  without 
these  organs  at  the  same  time  containing  tubercles,  or  without  a  probability  that 
they  formerly  existed,  appear  to  me  very  rare  ;  yet  I  have  known  some  exam- 
ples. Very  recently,  I  found  at  the  hospital  of  La  Charite,  in  the  lungs  of  a 
man  of  sixty,  who  had  never  shown  any  symptom  of  pectoral  affection,  several 
calculi  of  a  stony  hardness,  and  with  branches  like  many  of  the  renal  calculi. 
In  consequence  of  their  shape,  ought  not  these  calculi,  which  had  an  average 
size  of  a  hazel-nut,  to  be  considered  as  having  originated  rather  in  the  bronchial 
ramifications  than  in  the  p*enchyma  of  the  lungs  itself?  This  parenchyma 
besides,  was  in  all  parts  very  sound. 

But  the  most  remarkable  instance  of  this  kind  that  1  have  ever  seen,  was  that 
of  a  middle  aged  woman,  whose  lungs  contained  a  great  number  of  calcareous 
concretions,  while  the  tissue  was  otherwise  unaltered  ;  they  were  also  found  in 
great  numbers  in  most  of  the  lymphatic  glands  of  the  body,  viz.  in  those  of  the 
arm  pits,  the  bronchi  and  the  mesentery,  where  they  united  and  formed  regular 
tumors.  The  respiratory  system  during  life,  had  suffered  no  particular  trouble. 
Jlndral. 


MELANOSIS  OF  THE  LUNGS. 


411 


part  of  the  lungs  rendered  impermeable  to  air  from  the  cicatriza- 
tion of  tuberculous  excavation.*  ' 


CHAPTER  XL 

OF    MELANOSIS    OF    THE    LUNGS. 

The  older  surgeons,  and  after  them,  the  modern  anatomists,  have 
confounded  under  the  name  of  Scirrhus,  Cancer,  or  Carcinoma, 
different  morbid  growths  which  have  no  common  character  but 
that  of  their  being  unlike  any  of  the  natural  or  healthy  tissues  of 
the  body, — their  originating  in  an  indurated  sfete, — and  their 
subsequent  softening  and  self-destruction. f  This  confusion  has 
proved  a  great  bar  to  the  progress  of  morbid  anatomy.  Con- 
vinced of  this,  I  have  paid  particular  attention  to  the  discrimina- 
tion of  these  various  productions,  and  have  succeeded  in  pointing 
out  several  very  distinct  species.  That  which  I  have  now  to 
notice,  and  which  I  described  many  years  ago,  (1806,)  in  an  un- 
published memoir  presented  to  the  Faculte  de  Medicine,  is  the 
most  easily  recognized  in  all  the  organs  except  the  lungs,  in  which, 
owing  to  its  color,  it  is  sometimes  distinguished  with  much  dif- 
ficulty, from  the  black  pulmonary  matter. 

In  their  early  or  crude  state,  these  productions  possess  a  con- 
sistence equal  to  that  of  the  lymphatic  glands,  and  a  homoge- 
neous and  somewhat  humid  composition  ;  they  are  opaque,  and, 
in  structure,  very  much  resemble  the  bronchial  glands  in  the 
adult.  When  they  begin  to  soften,  a  minute  portion  of  fluid  can 
be  expressed  from  them,  of  a  thin  reddish  character,  intermixed 
with  small  blackish  portions  of  a  substance  which  is  sometimes 
firm,  sometimes  friable,  but  which,  even  when  friable,  conveys  to 
the  touch  an  impression  of  flaccidity  :  in  a  more  advanced  stage, 
these  portions  first,  and  subsequently  the  whole  mass  in  which 
they  are  contained,  become  quite  friable,  and  are  soon  converted 
into  a  black  paste.J 

*  These  bony  concretions  generally  consist  of  a  large  proportion  of  phosphate 
of  lime,  a  small  proportion  of  carbonate  and  animal  matter.  See  Thomson's 
Chemistry,  5th  edit.  vol.  iv.  p.  572.  See  also  Dr.  Prout's  Analysis,  Lond.  Med. 
Repost.  vol.  xii.  p.  352. —  Transl. 

t  See  Diet,  des  Sc.  Med.  Art.  Anat.  Pathol. ;  also  Journ.  de  Med.  t.  ix.  for  Jan. 
1805.— Author. 

%  Laennec's  view  of  the  formation  and  progress  of  melanosis  is  now  very 
generally  abandoned  by  pathologists.  The  following  extracts  from  the  work  of 
Dr.  Carswell,  the  highest  authority  on  this  subject,  gives,  I  believe,  an  accurate 
representation  of  the  facts]: — "  Only  two  changes  are  observed  to  take  place  in 
the  melanotic  matter  after  its  deposition.     The  first  consists  in  the  inspissation 


412  MELANOSIS    OF    THE    LUNGS. 

Melanosis  may  exist  in  four  different  forms,  viz  :  1.  encysted  ; 
2.  non-encysted  ;*  3.  impregnating  or  infiltrated  into  the  natural 
substance  of  an  organ  ;  and  4.  deposited  on  the  surface  of  an 
organ. 

1 .  Encysted  melanosis. — The  cysts  enclosing  this  species  are 
very  regularly  rounded,  and  vary  in  size  from  that  of  a  small 
hazel-nut  to  that  of  a  walnut.  At  least,  I  have  never  met  with 
any  that  did  not  come  within  these  dimensions.  They  have  a 
very  regular  and  equal  thickness,  which  is  never  greater  than 
half  a  line.  Cellular  substance  appears  to  be  the  only  tissue  that 
enters  into  their  composition.  They  adhere,  by  means  of  a  very 
fine  cellular  tissue,  to  the  substance  of  the  organ  in  which  they  are 
situated,  and  from  which  they  can  be  readily  separated  by  dis- 
section. Their  interior  surface  is  rather  smooth,  but  adheres  to 
the  morbid  mat'ter  which  it  surrounds.  The  medium  of  this  ad- 
hesion appears  to  me  to  be  a  very  fine  imperfect  cellular  tissue, 
though  it  cannot  always  be  distinguished.  I  have  hitherto  only 
found  this  variety  of  melanosis  in  the  liver  and  lungs  ;  and,  in  the 
latter  organ,  I  have  only  as  yet  met  with  a  single  mass  of  it. 

2.  Vnencysted  melanosis. — This  variety  is  much  less  rare  than 
the  preceding :  I  have  met  with  it  in  the  lungs,  the  liver,  pituitary 
gland,  and  the  nerves ;  but  it  has  been  since  found  in  almost 
every  organ.  The  volume  of  masses  of  this  kind  is  quite  inde- 
terminate,— varying  from  that  of  a  millet-seed  to  that  of  an  egg, 
or  more.  They  are  also  quite  irregular  in  figure.  They  com- 
monly adhere  very  closely  to  the  parts  in  which  they  are  situated  ; 
sometimes,  however,  they  are  united  to  these  by  a  very  fine, 
though  sufficiently  visible,  cellular  tissue,  which  permits  their  re- 
moval wjthout  any  laceration.  In  this  last  case  they  are  com- 
monly of  a  rounded  shape. 

3.  Impregnation  of  the  natural  tissue  with  the  matter  of  me- 
lanosis.— It  frequently  happens  that  this  morbid  matter,  in  place 
of  being  segregated  in  distinct  masses,  is  disseminated  through- 

or  solidification,  the  second  in  the  softening  or   liquefaction   of  the   melanotic 

matter The  material  of  which  melanosis  is  composed  exists  primarily,  in 

a  fluid  form,  and  every  increase  of  consistence  which  it  afterwards  acquires,  is 
owing,  chiefly,  either  to    its  combination  with  the   molecular  structure,  or  the 

dense  unyielding  nature  of  the  tissues  or  organs  in  which   it  is  deposited 

It  follows  as  a  consequence,  that  the  process  of  softening  cannot  take  place  until 
that  of  solidification  has  been,  at  least,  carried  to  a  certain  extent :  perhaps  it 
never  does  take  place  until  it  has  been  carried  to  its  maximum  ;  for  the  soften- 
ing of  the  melanotic  deposit  is  observed  only  when  it  has  acquired  the  form  of  a 
tumor,  or  occupies  an  irregular  portion  of  an  organ.  Under  these  circumstances, 
the  softening  of  the  hardened  melanotic  mass  is  effected  in  the  two  following 
ways  :  first,  by  the  destruction  of  tissues  included  within  it  and  around  it;  sec- 
ond, by  the  effusion  ofserosity  caused  by  its  stimulating  power  as  a  foreign  body. 
The  liver  and  lungs  furnish  the  best  examples  of  softening  of  melanotic  tumors 
from  destruction  of  the  tissues  in  which  they  are  formed."  (Cijc.  of  Pract.  Med. 
vol.  iii.  p.  95.) — Transl. 


MELANOSIS    OF    THE    LUNGS. 


413 


out  the  organs  in  which  it  is  found,  and  deposited  between  the 
particles  or  molecules  of  the  natural  tissue.  The  appearances 
and  color  of  parts  affected  in  this  manner,  present  a  good  many 
varieties,  according  to  the  texture  of  the  organ,  the  quantity  of 
morbid  matter  deposited,  and  the  particular  condition  of  this 
matter.  When  the  infiltration  is  recent,  and  in  moderate  quan- 
tity, the  appearance  of  the  affected  part  merely  differs  from  the 
natural  condition  in  being  intermixed  with  small  black  dots  or 
striae,  the  intermediate  portions  being  quite  of  a  healthy  charac- 
ter. As  the  disease  increases,  the  dots  and  striae  enlarge  in  num- 
ber and  volume,  until  the  whole  of  the  natural  tissue  of  the  part 
is  lost  in  the  morbid  degeneration.  It  is  usually  only  at  this  pe- 
riod of  its  progress  that  the  melanose  matter  begins  to  soften ; 
but  if  the  softening  takes  place  before  the  complete  removal 
of  the  natural  tissue  of  the  part,  it  frequently  happens  that  this 
softens  also,  and  intermingles  with  the  morbid  matter,  the  color  of 
which  is  thereby  changed  to  brownish,  yellowish,  or  greyish.* 

Melanosis,  like  all  the  other  accidental  productions  which 
differ  from  the  natural  tissues  of  the  animal  economy,  gives  rise 
to  constitutional  and  local  disorder.  Among  the  constitutional 
or  general  effects,  the  most  constant  are,  the  gradual  diminution 
of  the  vital  powers,  and  a  marked  change  in  the  process  of  nu- 
trition, whence  result  emaciation  to  a  considerable  degree,  and 
dropsy  of  the  cellular  membrane,  and,  sometimes,  of  the  serous 
membranes.  The  subjects  whom  I  have  known  to  die  in  conse- 
quence of  melanosis  in  any  organ,  had  no  continuous  or  well- 
marked  fever ;   and  this  is  true  of  cases  wherein  the  disease  ex- 

*  Laenncc  has  omitted  to  notice  here  the  fourth  variety  of  melanosis,  that, 
namely,  deposited  on  the  surface  of  organs;  probably  because  he  treats  of  it  in 
the  chapter  on  the  accidental  productions  of  the  pleura.  MM.  Breschet  and 
Andral  recognize  still  another  form  of  melanosis,  viz.  one  primarily  fluid.  An- 
dral  (Prtcis.  d'Jlnat.  Path.  t.  i.  p.  456.)  adduces  as  example  of  this  :  1.  certain 
cases  of  chronic  peritonitis  in  which  the  peritoneum  contained  a  very  black 
fluid  ;  2.  a  case  of  black  urine  observed  by  Proust,  and  in  which  this  learned 
chemist  conceives  that  he  discovered  a  new  acid,  termed  |by  him  melanic  acid  ; 
3.  a  case  of  fibrous  cyst  containing  a  black  fluid,  found  in  a  horse  by  MM. 
Trousseaux  and  Leblanc  ;  and  4.  those  cases  of  black  or  chocolate-colored 
vomitings  so  common  in  cancer  of  the  stomach. — (M.  L.J 

The  omission  by  Laenncc  of  all  distinct  notice  of  liquid  melanosis  (with 
wliicli  he  was  Veil  acquainted,  and  which  is,  in  fact,  the  same  as  his  fourth 
form)  is  well  accounted  for  by  Dr.  Carswell : — "  It  is  (he  says)  obviously  to  be 
referred  to  a  fundamental  error  in  the  pathological  doctrines  which  he  main- 
tainedj  regarding  the  mode  of  formation,  development,  and  termination  of  acci- 
dental or  new  products;  for  he  believed  that  all  these  products  possessed  at  first 
a  greater  or  less  degree  of  density,  to  which  state  he  gave  the  name  of  crudity  ; 
and  thai  they  afterwards  undergo,  at  some  period  or  other  of  their  existence,  by 
means  of  some  change  taking  place  within  themselves,  a  process  of  solution, 
which  he  describes  as  the  period  or  state  of  softening  The  idea,  therefore,  of 
melanosis  existing  primarily  In  a  fluid  form,  was  repugnant  to  such  doctrines; 
consequently  this  form  of  the  disease  could  not  be  admitted  by  him  into  the 
class  of  accidental  tissues,  to  which  he  conceived  melanosis  to  belong." 
(Cyc.  of  Prac.  Med.  vol.  iii.  p.  65.) — Transl. 


414  MELANOSIS  OF  THE  LUNGS. 

tended  to  a  great  portion  of  the  lungs,  and  is  also  observablo  in 
the  two  cases  (XX.  and  XXI.)  of  the  same  affection  given  in 
the  work  of  M.  Bayle.  If  this  circumstance  holds  good  gene- 
rally, as  I  am  much  disposed  to  believe,  it  will  assist  in  enabling 
us  to  distinguish,  during  life,  consumption  produced  by  mela- 
nosis of  the  lungs,  from  that  depending  on  tubercles ;  which 
last,  as  is  well  known,  is  accompanied,  through  almost  its  whole 
course,  by  a  hectic  fever,  which  is  usually  characterized  by  two 
exacerbations, — one  towards  mid-day,  and  the  other  in  the  night. 
The  most  constant  of  the  local  effects  produced  by  melanosis  of 
the  lungs,  are  dyspnoea,  proportioned  to  the  extent  of  the  dis- 
ease, and  cough,  which  is  often  dry,  but  sometimes  attended  by 
a  mucous  expectoration  intermixed  with  some  puriform  sputa. 
The  melanose  masses  in  the  lungs  may  be  sometimes  completely 
softened,  so  as  to  leave,  after  their  evacuation  into  the  bronchi, 
cavities  resembling  those  produced  by  the  softening  down  of  tu- 
bercles. I  have  myself  never  met  with  excavations  of  this  sort 
in  the  lungs ;  I  have  met  with  them,  however,  in  the  liver ;  and 
the  work  of  M.  Bayle  contains  two  cases  (XX.  and  XXI.) 
which  incontestably  prove  the  possibility  of  their  formation  in  the 
lungs.  In  these  cases  the  pulmonary  tissue,  so  much  impreg- 
nated with  melanose  matter  as  to  be  as  firm  as  liver,  (or  even 
firmer,)  contained  a  multitude  of  small  excavations  evidently 
formed  by  the  partial  softening  of  the  same  matte*.  It  is  clear 
that  in  cases  of  this  kind,  pectoriloquy  would  be  found  wherever 
such  excavations  came  to  communicate  with  the  bronchi.*  It  is 
equally  evident  that  the  stethoscope  would  enable  us  to  ascertain 
the  impermeability  of  the  lungs,  in  the  cases  in  which  the  matter 
of  melanosis  was  diffused  through  the  substance  of  these  organs  ; 
but  could  not  enable  us  to  distinguish  it  from  chronic  pneu- 
monia. 

Melanosis  is  one  of  the  rarest  species  of  cancer,  and  is  very 
seldom  met  with  in  the  lungs.  This  may  seem  an  extraordinary 
assertion  after  the  contrary  assertion  of  M.  Bayle,  and  the  cases 

*  M.  Bayle's  cases,  as  has  been  justly  remarked  by  Andral,  (Diet,  dc  Med.  t. 
xiv.  Art.  Melanose,)  by  no  means  prove  that  the  pulmonary  cavities  mentioned 
in  them,  were  the  consequence  of  softening  of  the  melanotic  masses.  There 
had  been,  during  life,  no  black  expectoration  ;  no  black  matter  was  found  in  the 
bronchi  after  death,  nor  yet  in  the  cavities  themselves,  which  were,  on  the 
contrary,  lined  by  a  membrane  covered  with  white  pus.  It  is,  therefore,  more 
than  probable  that  the  excavations  were  of  a  tuberculous  character,  and 
were  surrounded  by  a  tissue  impregnated  with  melanotic  matter.  Moreover, 
Andral  regards  as  extremely  rare  the  softening  of  melanotic  matter,  and  even 
seems  disposed  to  reject  it  altogether.  (Loc.  Cit.  &  Precis  d'Jinat.  Path.  t.  i. 
p.  450.)  According  to  him,  the  softening,  in  certain  cases,  is  dependent  on  that 
of  the  natural  or  accidental  tissues  with  which  the  melanotic  matter  was  united  ; 
while,  in  others  the  supposed  softening  was  merely  the  existence  of  melanosis, 
deposited  in  a  liquid  form,  in  substance  or  on  the  surface  of  other  tissues.— 
(M.  L.) 


MELANOSIS  OF  THE  LUNGS. 


415 


given  in  his  work  under  the  name  of  Phthisis  with  Melanosis. 
Whatever  distrust  I  may  have  of  my  own  opinions  when  they 
differ  from  those  of  that  excellent  observer,  with  whose  extreme 
correctness  I  had  better  opportunities  of  being  acquainted  than  any 
other  person, — I,  nevertheless,  cannot  help  being  of  opinion,  that 
he  was  deceived  on  this  particular  point,  and  that  he  sometimes 
confounded  with  melanosis  the  natural  black  pulmonary  matter. 
I  admit  that  these  two  substances  are  very  much  alike  in  their 
external  characters,  and  I  am  not  sure  that  the  most  experienced 
observer  could  discover  any  difference  between  a  melanose  mass 
in  the  liver  or  any  other  organ,  and  a  bronchial  gland  of  a  per- 
fectly black  color,  such  as  they  are  often  found  in  very  sound 
lungs.  I  will  not  say  that  the  following  characters  suffice  to 
distinguish  the  two  substances,  but  they  may  at  least  assist  us 
in  discriminating  them ; — The  matter  of  melanosis  when  soft- 
ened, and  even  that  which  can  be  expressed  from  it  while  yet 
solid,  dyes  the  skin  black ;  but  this  color  is  not  very  permanent, 
and  can  be  easily  removed  by  washing ;  while  the  blackness  pro- 
duced by  the  matter  of  the  bronchial  glands,  if  this  be  left  to  dry 
before  washing,  will  remain  on  the  skin  for  several  days.  The 
chemical  composition  of  the  two  bodies  also  differs  very  consider- 
ably. The  bronchial  glands,  according  to  Fourcroy,  contain  a 
large  portion  of  carbon  and  hydrogen,  while  the  matter  of  mela- 
nosis contains  neither  of  these,  but  is  almost  entirely  composed 
of  albumen  and  a  peculiar  coloring  matter.* 

Notwithstanding  its  resemblance  to  a  black  bronchial  gland, 
melanosis  is  evidently  a  morbid  and  very  deleterious  production, 
inasmuch  as  it  produces  all  the  local  and  general  effects  of  other 
cancers,  when  it  exists  in  a  certain  extent ;  and  since  it  is  found 

*  MM.  Lassaignc  and  Foy  have  analysed  the  matter  of  melanosis.  The  for- 
mer detected  in  it  fibrine,a  peculiar  black  coloring  matter,  a  little  albumen,  and 
various  salts,  among  which  were  the  phosphate  of  lime  and  the  oxide  of  iron  ;  the 
second  found  much  albumen,  a  small  quantity  of  fibrine,  a  very  large  proportion 
of  a  principle  eminently  carbonized — apparently  a  modification  of  the  cruor  of 
the  blood  ;  and,  lastly,  the  various  salts  including  the  two  mentioned  in  the  anal- 
ysis of  M.  Lassaigne.  It  is  evident  from  these  analyses  that  the  constituent  prin- 
ciples of  melanosis  are  nearly  the  same  as  those  of  the  blood,  there  being  merely 
a  predominance  of  carbon,  and  consequently,  that  there  is  no  essential  chemical 
difference,  as  Laennec  supposed,  between  the  matter  of  melanosis  and  that  of  the 
black  bronchial  glands — (M-  L.) 

The  following  are  the  particulars  of  the  analysis  by  M.  Foy,  of  the  melanotic 
tumor  of  the  horse: — 

.  5,00 
.  3,75 
.  2,50 
.  3,75 
.  1,75 
.  1,75 
Dr.  Henry,  of  Manchester,  has  also  given  an  elaborate  analysis  of  the  matter 
of  melanosis,  and  with  results  nearly  similar. — See  Faiodington  on  Melanosis. — 
TransL 


Albumen 

15,00 

Muriate  of  Potass 

Fcbrine 

6,25 

Ditto         Soda 

Carbonized  Principle 

31,40 

Carbonate  of  Soda 

Water 

18,75 

Ditto        Lime 

Oxide  of  Iron 

1,75 

Ditto        Magnesia 

Sub-phosphate  of  Lime 

8,75 

Tartrate  of  Potass 

416  MELANOSIS  OF  THE  LUNGS. 

united  with  other  morbid  productions  in  compound  cancerous 
tumors.  When  melanosis  forms  masses  of  considerable  extent, 
or  when  it  impregnates  the  pulmonary  tissue  so  thoroughly  as  to 
give  it  a  deep  black  color,  and  a  consistence  equal  to  that  of  liver, 
it  is  easily  .recognized  ;  but  when  the  impregnation  is  recent,  and 
not  sufficiently  abundant  to  produce  any  considerable  induration 
of  the  lung,  it  can,  with  difficulty,  be  distinguished  from  the  black 
pulmonary  matter.* 

I  have  already  mentioned  this  black  pulmonary  matter  sev- 
eral times.  It  has  been  little  noticed  by  anatomists ;  yet  it  ex- 
ists so  commonly  in  the  lungs,  and  even  in  persons  in  the  most 
perfect  health,  that  we  can  hardly  consider  it  as  a  morbid  pro- 
duction. It  is  found  more  or  less  abundant  in  the  lungs  of  almost 
every  adult,  and  seems  to  increase  with  the  age  of  the  individual. 
In  early  infancy,  we  perceive  no  trace  of  it,  and  the  lungs  are  of 
as  pure  a  rose  color  as  those  of  the  ox  and  several  other  animals. 
Perhaps  this  peculiar  matter  exists  only  in  man,  and  the  carniv- 
orous animals  ;  but  I  have  been  too  little  practised  in  compa- 
rative anatomy  to  advance  any  thing  positive  on  the  subject.  I 
have  sometimes  imagined  that  this  matter  may  arise,  at  least  in 
part,  from  the  smoke  of  lamps  or  other  bodies  in  combustion, 
since  we  find  some  old  subjects  (and  I  have  thought  these  were' 

*  The  efforts  of  Laennec  to  establish  a  distinction  between  the  matter  of  me- 
lanosis and  the  black  pulmonary  matter,  have  been  generally  regarded  as  futile  ; 
and  most  of  the  anatomists  of  the  present  day  consider  melanosis  not  as  an  acci- 
dental production,  in  the  sense  in  which  this  word  is  used  by  Laennec,  but 
merely  an  impregnation  of  a  tissue,  whether  normal  or  morbid,  with  a  black 
matter  of  a  peculiar  kind.  The  only  difference  recognized  between  the  two  af- 
fections, is,  that  in  the  one  case,  the  coloring  matter  impregnates  a  healthy  tissue, 
while  in  the  other  (melanosis)  it  impregnates  an  accidental  or  morbid  tissue; 
the  alleged  softening  of  melanosis  being  merely  the  softening  of  the  tissue  where- 
with the  coloring  matter  is  combined.  But  what  is  the  nature  of  this  black  mat- 
ter? Is  it  merely  altered  blood,  as  M.  Bresehet  supposes,  and  as  the  chemical 
analysis  tends  to  prove,  or  is  it  a  peculiar  morbid  product,  as  M.  Andral  sup- 
poses ?  It  is  probably  produced  in  both  ways. — (M.  L.) 

Dr.  Carswell  agrees  with  those  who  regard  the  matter  of*  melanosis  as  essential- 
ly composed  of  the  coloring  material  of  the  blood,  and  states,  that  it  is  formed  in 
the  blood  in  the  first  instance,  and  afterwards  deposited  by  secretion  in  the  va- 
rious parts  where  it  is  found.  "  It  is  not  only  (says  Dr.  C.)  because  this  material 
is  seen  in  the  blood  that  we  have  fixed  its  seat  in  this  fluid,  but  because  our  ana- 
tomical researches  show  that  it  is  there  formed."  '•  The  much  greater  fre- 
quency of  melanosis  in  the  grey  and  white  than  in  the  bay,  brown,  or  black 
horse,  (continues  Dr.  C.)  is  a  circumstance  of  some  importance,  and  which 
may  be  regarded  as  favorable  to  the  theory  which  ascribes  the  origin  of  melano- 
sis to  the  accumulation  in  the  blood  of  the  carbon  which  is  naturally  employed 
to  color  different  parts  of  the  body,  and  more  particularly  the  hair.  This  theory 
we  are  disposed  to  adopt,  not  only  as  regards  the  formation  of  the  disease  under 
these  circumstances  of  color,  but  also  when  it  occurs  in  animals  of  a  dark  color 
and  in  man  indiscriminately,  whatever  may  be  the  peculiar  tint  of  the  skin  or 
color  of  the  hair.  In  the  first  instance,  the  coloring  matter  formed  is  not 
deposited  in  the  regular  physiological  order  :  in  the  second  it  is  formed  in  too 
great  quantity.  In  both  cases,  its  presence  and  accumulation  in  the  blood  is 
accounted  for."— Cijc.  of  Pract.  Med.  vol.  iii.  p.  05.—  Trand 


MELANOSIS    OF    THE    LUNGS. 


417 


most  commonly  country  people  least  accustomed  to  the  use  of 
artificial  lights)  in  whom  it  exists  in  very  small  quantity  both 
in  the  lungs  and  bronchial  glands.  I  must  admit,  however,  that 
I  have  seen  the  same  slight  degree  of  coloring  in  individuals 
who  had  been  much  exposed  to  this  cause  ;  as  in  one  of  the  cases 
detailed  at  the  close  of  this  chapter.*     When  it  exists  only  in 

*  It  appears  to  me  incontestable  that  the  black  color  which  the  lungs  assume 
late,  in  life,  is  most  commonly  the  result  of  a  morbid  secretion  analogous  to  that 
which  takes  place  regularly  in  other  parts  of  the  body,  as,  for  example,  on  the 
inner  surface  of  the  sclerotic  coat  of  the  eye.  This  same  coloring  matter  in 
divers  shades,  is  spread  in  profusion  throughout  the  whole  organized  kingdom, 
animal  and  vegetable.  Observations,  however,  recently  made  in  England,  leave 
no  doubt  that  in  some  cases  the  black  color  of  the  lungs,  is  owing  to  the  long 
and  habitual  breathing  of  an  atmosphere  charged  with  black  dust,  charcoal,  for 
instance.  In  fact,  the  lungs  of  colliers  have  been  found  deeply  blackened  both 
externally  and  internally.  Of  these,  some  died  of  disorders,  not  pectoral;  and 
it  docs  not  appear  that  their  lungs,  though  containing  much  black  matter,  had 
suffered.  Others  died  with  symptoms  of  pectoral  disorders;  and  on  opening 
the  bodies,  the  lungs  exhibited  marks  of  chronic  inflammation  and  ulcerations 
similar  to  cavities.  In  litis  last  case,  it  is  to  be  presumed  that  the  disorder  of 
the  lungs  was  independent  of  the  black  matter. 

Here  are  some  of  the  cases.  I  will  quote  first  those  with  pectoral  affections. 
The  following  is  from  the  Medical  Gazette. 

Obs.  1 .  A  man  of  58,  a  laborer  in  the  coal  mines  from  infancy,  enjoyed  good 
health  till  the  las!  seven  years,  during  which  he  had  cough  and  dyspncea,  both 
which  increased  in  winter,  afterwards  purulent  expectoration,  emaciation  and 
s\  rnptoms  of  pulmonary  phthisis.  In  March,  1833,  the  matter  of  expectoration 
began  to  turn  black  as  ink;  the  epiantity  was  considerable,  sometimes  a  quart 
in  twenty-four  hours.  The  stethoscope  discovered  cavernous  rhonchus  under 
the  right  clavicle,  and  the  absence  of  respiratory  murmur  in  the  left  side. 
Diarrhoea  occurred  in  the  last  moments  of  life.  On  dissection,  the  lungs  were 
found  transformed  into  black  masses,  exhibiting  not  a  vestige  of  their  natural 
color.  They  contained  vast  cavities  which  held  an  abundance  of  a  liquid,  black 
as  ink.  and  similar  to  that  which  had  been  expectorated  ;  other  liquids  expressed 
from  the  lungs  had  the  same  color. 

Ojss.  2.  A  man,  aged  62,  originally  of  a  good  constitution,  a  laborer  in  the 
coal  mines  from  infancy,  subject  to  rheumatic  pains,  and  particularly  to  fits  of 
dyspncea  in  cold  and  changeable  weather.  In  January,  1833, he  was  taken  with 
cough  and  palpitation  and  additional  oppression;  by  degrees,  the  symptoms  of 
phthisis  declared  themselves.  The  matter  expectorated  was  blackish  grey, 
resembling  mucus  mixed  with  soot.  On  dissection,  the  lungs  were  found  to 
contain  a  vast  cavity  full  of  black  matter;  the  same  matter  had  filtered  into  the 
lungs  and  filled  the  bronchi. 

Other  persons,  and  particularly  Dr.  Graham  (Edin.  Med.  and  Surg.  Journal,) 
have  published  eases  of  miners  who  died  from  falls  or  other  external  violences, 
and  whose  lungs  were  blackened,  yet  the  individuals  had  shown  no  symptoms 
of  pulmonary  disease. 

In  order  to  show  that  this  black  matter  is  not  produced  by  secretion,  Dr. 
Christison  submitted  it  to  a  chemical  analysis.  In  this  case  it  was  taken  from 
the  lungs  of  a  coal  miner  which  were  found  by  Dr.  Gregory  to  be  colored  black 
throughout.  It  was  found  that  hydrochloric  and  nitric  acid,  which  destroy 
all  organic  substances,  have  no  effect  upon  this  black  matter;  whence  Dr. 
Christison  concludes  it  is  not  the  result  of  secretion.  Dr.  Graham  has  come  to 
the  same  conclusion,  and  affirms  that  the  matter  comes  from  without,  relying 
among  oilier  proofs,  upon  the  fact  that  it  differs  in  its  properties  from  all  other 
black  matter  of  organic  origin;  thus  the  divers  black  pigments  found  in  ani- 
mals, lose  their  color  and  whiten  under  the  influence  of  chlorine,  while,  on 
the  contrary,  this  black  matter  undergoes  no  change  by  it. 

Ms  attention  had  already  been  excited  by  these  facts,  when  M.  Behier  of  the 

53 


418  MELANOSIS    OF    THE    LUNGS. 

small  quantity,  it  merely  gives  to  the  lungs  a  slight  grey  tint. 
On  the  surface  it  appears  in  small  disseminated  black  dots,  which 
are  more  numerous  and  thicker  along  the  intersecting  lines  of 
the  cells,  so  as  to  form  striae,  small  spots,  or  punctuated  lines. 
These  spots,  still  further  crowded  in  different  places,  as  well  in 
the  interior  as  on  the  surface  of  the  lungs,  form  spots  still  larger 
and  more  •  numerous,  so  as  sometimes  to  give  a  black  color  to 
large  portions  of  these  organs.  In  no  case,  however,  does  this 
matter  affect  the  suppleness  or  permeability  of  the  lung,  a  cir- 
cumstance which  forms  a  striking  contrast  with  the  melanose 
infiltration.  It  is  particularly  in  the  bronchial  glands  that  this 
black  matter  is  found  most  abundantly.  In  adults,  and  espe- 
cially in  old  persons,  they  are  often  found  completely  black  ; 
in  others  they  are  only  partially  stained,  as  if  touched  by  a 
pencil.  A  condition  of  parts  so  common  cannot  be  regarded  as 
capable  of  producing  disease,  especially  as  it  is  often  unattended 
by  any  symptom  whatever  of  disorder.  This  matter  in  the 
bronchial  glands  would  appear  to  be  the  cause  of  the  grey  color 
of  the  bronchial  mucus,  which  many  healthy  persons  expectorate, 
and  of  the  small  black  specks  found  frequently  intermixed  with 
that  transparent  secretion.  This  character  of  the  bronchial 
mucus  establishes  another  distinction  between  the  black  pul- 
monary matter  and  the  matter  of  melanosis,  as  the  existence  of 
the  latter,  even  in  the  greatest  degree,  never  gives  rise  to  an  ex- 
pectoration of  a  black  color,  unless,  perhaps,  at  the  very  mo- 
ment of  the  escape  of  the  softened  melanose  mass  into  the 
bronchi.* 

The  formation  of  tubercles  in  the  lungs,  and,  more  especially, 
the  cicatrization  of  the  tuberculous  excavations,  frequently  pro- 
duces, as  I  have  previously  observed,  a  more  abundant  secretion 

Hospital  La  Charite  sent  me  a  drawing  which  he  had  made  of  a  lung  entirely 
colored  black,  like  those  described  by  the  English  writers,  and  found  in  an 
individual  who  breathed  habitually  an  air  loaded  with  coal  dust. — Andral. 

*  In  the  Philosophical  Transactions  for  181 3,  Dr.  Pearson  has  given  an  account 
and  a  chemical  analysis  of  the  black  pulmonary  matter  as  existing  in  the  bron- 
chial glands.  I  give  the  result  of  Dr.  P's  examination  in  the  words  of  Dr. 
Young: — "  He  (Dr.  Pearson)  considers  the  bronchial  bodies  as  true  lymphatic 
glands,  and  thinks  the  black  substance  which  often  tinges  them,  consists  of 
charcoal,  derived  from  some  particles  of  dust  floating  in  the  atmosphere, 
which  have  been  taken  in  by  the  absorbents,  and  deposited  in  their  glands :  and 
he  has  found  some  of  the  lymphatics  occasionally  filled  with  a  similar  substance. 
He  supports  his  opinion  by  chemical  experiments,  which  show  the  insolubility 
of  the  black  substance  in  nitric  acid,  while  he  has  been  unable  to  find  any  other 
animal  substance,  the  ink  of  the  cattle-fish  not  excepted,  that  resists  the  action 
of  the  acid.  The  glands  of  the  mesentery,  he  says,  are  also  sometimes  black, 
but  their  blackness  disappears  upon  immersion  in  the  nitric  or  muriatic  acid." — 
Young  on  Consumption,  p.  468. 

Likewise  Dr.  Christison  (Edin.  Med.  Journ.,  vol.  36,  p.  393)  has  recorded  an 
analysis  of  the  black  matter  (evidently  derived  from  an  external  source)  found 
universally  discoloring  the  lungs,  in  the  very  interesting  case  by  Dr.  J.  C.  Grego- 
ry.    This  analysis  coincides,  in  the  main,  with  that  of  Dr.  Pearson.—  Transl. 


MELANOSIS  OF  THE  LUNGS. 


419 


of  the  black  pulmonary  matter.  In  some  cases,  this  abundance 
is  such,  as, — in  conjunction  with  the  compression  of  the  pulmo- 
nary tissue  produced  by  the  tubercles,  the  cartilaginous  cicatrices 
and  the  chalky  matter  that  accompanies  them, — to  render  the 
affected  part  considerably  indurated,  flaccid,  and  more  or  less 
impermeable  to  air.  In  extreme  cases  of  this  kind,  it  is  difficult 
to  say  whether  the  color  and  density  of  the  affected  part  are  the 
consequence  of  black  pulmonary  matter,  or  of  melanosis.  The 
rule  of  distinction  we  ought  to  follow  in  such  cases  is  the  fol- 
lowing : — We  ought  not  to  admit  the  existence  of  melanosis, 
unless  we  find  some  of  it  in  portions  of  some  extent,  and  already 
softened,  or,  at  least,  so  deposited  and  shaped,  as  to  distinguish 
it  from  bronchial  glands.  We  ought  not  to  admit  the  existence 
of  the  infiltration  of  this  matter,  unless  it  has  produced  in  the 
lungs  a  degree  of  induration  equal  to  that  of  liver :  and  when 
this  degree  of  hardness  can  be  traced  to  the  presence  of  bony  or 
cartilaginous  bodies,  we  ought  to  consider  the  black  color  as 
derived  from  the  black  pulmonary  matter.  To  render  this  dis- 
tinction more  easy,  I  shall  here  detail  two  cases.  The  first  is  an 
instance  of  melanosis  occurring  in  the  lungs,  and  in  several  other 
parts  of  the  body.  I  prefer  it,  because  it  exhibits  the  disease  in 
a  great  degree  of  development,  and  because  it  was  drawn  up 
neither  by  myself  nor  by  my  direction  ;  it  is  extracted  from  the 
register  of  cases  by  the  hospital  pupils  for  1816,  preserved  in 
the  office  of  the  board  of  administration.  The  second  case  offers 
an  example  of  the  difficulty  of  distinguishing  the  black  pulmo- 
nary matter  from  the  matter  of  melanosis.* 

Case  XXXI.  Melanosis  developed  in  a  great  number  of 
organs. — A  woman,  aged  fifty-nine,  entered  the  Hospital  Saint 
Louis  in  August,  1816,  for  an  affection  of  two  months'  standing, 
which  had  arisen  after  violent  grief.     The  disease  commenced 

*  For  a  complete  view  of  all  tliat  is  known  respecting  melanosis,  and  certain 
other  affections  which  have  been  confounded  with  it,  the  reader  is  referred  to 
the  Fourth  Fasciculus  of  Dr.  Carswell's  invaluable  work  on  pathological  anato- 
my, and  to  the  article  Melanosis,  by  the  same  author,  in  the  third  volume  of  the 
Cyclopaedia  of  Practical  Medicine.  Dr.  Carswell  adopts  the  generic  term  Me- 
lanoma, as  including  "  all  melanotic  formations,  black  discolorations,  or  pro- 
ducts described  by  Laennec  and  other  authors,"  but  separates  them  into  two 
great  groups,  terming  the  one  true  melanosis,  the  other  spurious  melanosis.  Un- 
der the  first  head  he  comprehends  all  the  black  formations  which  depend  on  a 
modification  of  the  secretory  process,  which  gives  rise  to  the  natural  color  of 
certain  parts  of  the  body,  that  is,  all  such  products  as  can  be  regarded  as  con- 
stituting an  idiopathic  disease  :  under  the  second,  he  ranges  all  those  which 
originate  in  the  accumulation  of  a  carbonaceous  substance  introduced  into  the 
body  from  without,  in  the  action  of  chemical  agents  on  the  blood,  or  in  the 
stagnation  of  the  blood  within  the  body.  Dr.  Carswell's  essay,  in  his  Patho- 
logical Anatomy,  is  illustrated  by  admirable  representations  of  the  disease,  not 
only  as  occurring  in  the  lungs,  but  in  most  of  the  other  organs  of  the  body. 
For  further  references  to  the  published  accounts  of  melanosis,  see  the  biblio- 
graphical notice  at  the  end  of  the  present  chapter. —  Transl. 


420  MELANOSIS  OF  THE  LUNGS. 

with  great  prostration  of  strength,  loss  of  appetite  and  Bleep. 
These  symptoms  were  followed  by  vomiting  and  diarrhoea,  and 
the  development  of  small  tumors,  of  a  black  color  in  different 
parts  of  the  skin.  When  she  came  into  the  hospital,  a  great 
number  of  these  tumors,  of  the  form  and  color  of  black  cur- 
rant seed,  occupied  the  anterior  part  of  the  thorax.  The  spaces 
between  some  of  these  were  filled  with  small  spots  very  like  flea- 
bites.  The  tumors  Avere  so  close  on  the  breasts  as  to  form  a  large 
plate  or  crust.  Some  of  the  same  sort  existed  in  the  abdomen, 
the  largest  being  two  inches  in  circumference.  The  arms  and 
thighs,  especially  on  their  inside,  were  marked  in  a  similar  man- 
ner ;  the  fore  arms  and  legs  were  without  any.  In  addition  to 
the  symptoms  already  mentioned,  the  respiration  was  difficult, 
there  was  frequent  cough,  and  the  pulse  was  extremely  quick. 
These  symptoms  gradually  increasing  in  degree,  and  being  followed 
by  oedema,  the  patient  shortly  after  died. 

Dissection. — The  cutaneous  tumors  were  found  to  consist  of 
a  homogeneous  substance,  of  a  more  or  less  deep  black  color,  and 
of  a  consistence  in  some  cases  very  considerable,  in  others  merely 
pulpy.  These  tumors  had  all  cysts  of  cellular  substance,  and  ap- 
peared to  be  evidently  of  the  kind  already  described  as  melanosis. 
They  were  found  in  almost  the  whole  of  the  subcutaneous  cellular 
tissue ;  also  in  the  same  tissue  which  incloses  the  vessels,  nerves, 
and  the  lymphatic  glands.  In  some  places  they  formed,  by  their 
aggregation,  masses  as  large  as  the  fist.  The  nerves  in  their  vi- 
cinity were  sound,  but  the  blood-vessels  could  not  be  separated 
from  them  without  rupture.  These  tumors  were  in  the  thyroid 
gland ;  also,  in  small  quantity,  in  the  lung.  In  the  neighborhood 
of  the  bronchial  glands  they  were  numerous  and  larger,  but 
the  bronchial  glands  themselves  were  not  black.  They  were 
seen  in  the  substance  of  the  mediastinum,  and  under  the  pleura; 
also,  in  great  numbers  in  the  mesentery  and  omentum.  All  the 
abdominal  viscera,  except  the  liver,  were  sound,  but  the  cellular 
substance  around  them  contained  similar  tumors.  The  heart  and 
brain  were  sound. 

Case  XXX.  Imperfect  cicatrices  in  the  lungs,  intermixed 
with  cartilaginous  and  chalky  productions,  and  a  great  accu- 
mulation of  black  pulmonary  matter. — A  man,  sixty  years  of 
age,  came  into  the  Necker  Hospital  in  October,  1817,  in  a  state 
of  marked  cachexy.  He  had  a  slight  cough,  with  expectoration 
of  a  grey,  semi-transparent,  and  somewhat  ropy  fluid,  which  led 
to  the  suspicion  of  tubercles.  He  continued  in  the  same  state 
until  the  end  of  January  following,  when  the  cough  became  some- 
what worse.  At  this  time  the  chest,  on  percussion,  seemed  not 
to  sound  very  well  on  the  upper  part  of  the  left  side  before,  and 
the  respiration  was  less  distinct  in  the  same  point.  These  results 
seemed  to  confirm  the  preconceived  idea  of  incipient  tubercles, 


MELANOSIS    OF    THE    LUNGS. 


421 


and  this  diagnostic  was  accordingly  made  in  the  case-book.  In 
the  end  of  March,  the  chest  was  found  to  yield  a  good  sound 
throughout.     He  died  on  the  13th  of  April. 

Dissection. — The    right    lung    was    attached    to    the    costal 
pleura  at  its  summit  by  means  of  a  firm    cellular  band,  which 
sprung   from  a   depression  in    the    lung,   irregularly  marked  by 
furrows  uniting  in  a   central  point,  and    having  every  appearance 
of  cicatrices.     Beneath    this  depression,  in    the  substance   of  the 
lung,  a  solid  tumor  was  felt,  of  the  size  of  a  pigeon's  egg,  which, 
on  incision,  was  found  to  consist  of  a  grey  semi-transparent  sub- 
stance, of  the    consistence  and    texture   of  cartilage,  intermixed 
with  small   portions  of  the  natural  tissue  of  the  lung,  only  very 
black  and  flabby.      There  were  also  found  in  it  small  cavities 
filled  with  a  soft  chalky  matter.     The  whole  lobe  was  one  quarter 
smaller  than  natural,  and  almost  entirely  of  a  dark  hue,  varying, 
in  different  points,  from  a  slate  color  to  that  of  the  blackest   ink. 
In  the  interstices  of  the  cartilaginous  bands,  there  were  several 
small  cavities,  quite  empty,  and  of  the  size  of  a  hemp-seed.     Seve- 
ral bronchial  tubes,  much   dilated,  terminated   in  this  indurated 
mass.     One  of  these,  as  large  as  a  goose-quill  before  entering  the 
tumor,  was  contracted   immediately  within    it   to  the   size   of  a 
crow-quill,  and    finally  terminated  abruptly  in  the  centre  of  the 
mass  without  giving  off  any  other  branch.     The  middle   and  in- 
ferior lobes  were  pretty  sound,  but  contained  a  few  miliary  tuber- 
cles.    The  upper  lobe  on  the  left  side  presented  the  same  appear- 
ances as  the   right,  only  in  a  still  more  marked  degree.     In  this, 
the  depression  was  several  lines  deep,  and  an  inch    square,  and 
was    partly  covered   by  the  overlapping  of  the  adjoining   portion 
of  sound  lung.     A  cellular  band    from  the  centre  of  this  depres- 
sion united  the  lobe  to  the  costal  pleura.     The  whole  summit  of 
this  lobe,  as    low  as  the  third   rib,  was  indurated  and  variegated 
precisely  as  that  on  the  other  side.     There  were  adhesions  between 
the  heart  and  pericardium,  and  the  ventricles  were  enlarged.     The 
abdomen    contained  a  large  quantity  of  a  yellowish   limpid  fluid. 
The  whole  peritoneum  was  of  a  dirty  grey  color,  and  studded 
with   innumerable    small,  red,  grey,  or  black  points.      The  red 
points,  united  in    flakes,  had   all  the  marks  of  being  the  result  of 
an  ancient   inflammation.     The   others  seemed  to  be  tubercles 
in  the  first  stage,  grey  and  semi-transparent ;  they  formed  small 
tumors  on  the  surface  of  the  membrane,  and  some  of  them  were 
of  the  size  of  large   hemp-seeds.       Those  which  were  of  a  black 
color  and  opaque,  were  evidently  formed  of  the  matter  of  mela- 
nosis.    These  two  species  of  tubercles  were  most  numerous  on 
the  intestinal  portion  of  the  peritoneum  ;  the  red  spots  or  flakes 
were,  on  the  other   hand,  most  plentiful  on  the  mesentery  and 
omentum.     This  last  was  rolled  together,  so  as  to  form  a  sort  of 


422  MELANOSIS  OF  THE  LUNGS. 

hard  and  irregular  tumor  in  the  left  hypochondrium.  The  peri- 
toneum seemed  much  thicker  and  much  softer  than  natural ;  but 
this  arose  from  its  being  covered  throughout,  between  the  granu- 
lations above  mentioned,  with  a  thin  and  soft  coating  or  layer  of 
albumen. 

In  the  first  of  these  cases,  there  can  be  no  doubt  of  the  nature 
of  the  black  tumors  found  in  the  lungs.  The  co-existence  of 
similar  tumors  in  divers  other  parts  of  the  body,  and  the  absence 
of  the  black  color  in  the  bronchial  glands  themselves,  leave  no 
doubt  on  the  subject.  In  the  second  case,  the  question  as  to  the 
nature  of  the  black  matter  in  the  indurated  portions  of  the  lungs, 
is  much  more  difficult.  The  fact  of  the  existence  of  bodies  an- 
swering to  the  character  already  assigned  to  pulmonary  cicatrices, 
and  also  of  bony  and  cretaceous  tumors,  and,  further,  the  im- 
mature tubercles  in  other  parts  of  the  lungs,  as  well  as  on  the 
surface  of  the  peritoneum, — all  tend  to  support  the  opinion  of  the 
black  color  being  produced  merely  by  the  black  pulmonary 
matter.  On  the  other  hand,  the  existence  of  some  melanose  tu- 
mors on  the  peritoneum  give  some  color  to  the  suspicion,  of  the 
black  portion  of  the  lungs  having  derived  their  origin  from  the 
same  source.  The  arguments,  however,  are  decidedly  in  favor  of 
the  former  opinion. 

I  have  already  observed,  that  M.  Bayle  appears  to  have  some- 
times confounded  the  matter  of  melanosis  with  the  common  black 
pulmonary  matter.  I  think  he  has  been  equally  wrong  in  class- 
ing melanosis  of  the  lungs  as  a  species  of  phthisis.  In  fact,  the 
melanose  affection,  in  place  of  producing  progressive  emaciation 
and  hectic  fever,  the  most  constant  symptoms  of  tuberculous  phthi- 
sis, rather  tends  to  produce  cachexy  and  anasarca,  and  usually 
proves  fatal  before  the  supervention  of  any  marked  degree  of  ema- 
ciation. If  we  were  to  class  diseases  from  so  feeble  analogies, 
we  ought  to  range  among  consumptions,  chronic  pleurisy,  pneu- 
mony,  and  catarrh,  as  well  as  several  affections  of  the  heart,  or, 
indeed,  every  disease  attended  by  dyspnoea  and  emaciation. 

In  medical  writings  we  find  but  few  cases  which  can  be  referred 
to  this  disease,  melanosis  ;  a  circumstance  which,  no  doubt  proves 
its  extreme  rarity  ;  since  its  characters,  especially  when  occurring 
in  any  other  organ  besides  the  lungs,  are  so  well  marked,  as  hardly 
to  be  mistaken.  Haller  relates  (Opus.  Pathol.)  some  of  the  best 
marked  instances  of  it.  "  I  have  observed,"  he  says,  "  a  horrible 
species  of  pulmonary  consumption.  In  a  man  I  found  one  lung 
filled,  not  with  pus,  but  with  a  matter  black  as  ink  ;  and  in  an- 
other I  have  since  found  a  similar  fluid  in  the  cavity  of  the  ple- 
ura." Notwithstanding  the  brevity  of  these  notices,  it  is  impossi- 
sible  to  mistake,  in  the  first,  the  infiltration  of  the  lungs  with  the 


ENCEPHALOID  TUMOR  OF  THE  LUNGS. 


423 


melanose  matter  in  a  soft  state  ;  and,  in  the  second,  a  secretion  of 
the  same  matter  in  the  pleura.* 


CHAPTER  XII. 

OF  ENCEPHALOID,  OR  MEDULLARY  TUMOR  OF  THE  LUNGS. 

This  species  of  accidental  production,  which  was  described  for 
the  first  time  in  the  Diet,  des  Sciences  Med.,  under  the  term 
Encephaloides,  is  one  of  those  that  has  been  most  frequently  con- 

*  I  have  never  found  black  matter  accumulated  in  the  cavity  of  the  pleura, 
but  I  have  often  seen  small  blackish  masses  scattered  over  the  serous  mem- 
branes, or  rather  under  them,  in  the  cellular  tissue  connecting  them  with  the 
subjacent  tissues.  The  peritoneum  appears  to  me  the  membrane  most  com- 
monly affected  with  melanosis,  which  at  first  may  be  mistaken  for  a  slight 
sanguine  effusion,  and  in  fact  in  some  cases  this  appears  to  be  the  real  condition  : 
in  some  parts  the  effused  matter,  instead  of  an  inky  blackness,  has  a  red  tint, 
like  blood;  in  other  parts  it  is  of  a  deeper  color,  and  in  others  quite  black:  in 
proportion  as  the  color  is  deeper,  the  matter  is  more  solid  and  consistent.  This 
fact,  which  I  have  repeatedly  observed,  may  be  offered  as  a  proof  in  support  of 
the  opinion  that  melanosis  is  nothing  but  extravasated  blood  which  has  under- 
gone divers  transformations  in  the  organic  tissues  where  it  is  found  deposited. 
Andral. 

LITERATURE  OF  MELANOSIS  OF  THE  LUNGS. 

1755.  Haller.     Opus.  Pathol.  (Obs.  xvii.)  Lausanne.  8vo. 

1810.  Baylc.     Recherches  sur  la  Phthisic     Par.  8vo. 

1813.  Gohier.     Mem.  et  Obs.  sur  la  Chirurgie  et  la  M6d.  Veter.     Lyon. 

1817.  Alibert.     Nosologic  Nat.  t.  i.  Par.    4to. 

Chornel.     Nouv.  Journ.  de  Med.  t.  iii. 
1821.  Breschet  (G.)  Considerations  sur  une  alteration  organique  appellee  De- 

generescence  Noire,  Melanose,  <fcc.     Par.  8vo. 
1823.  Heusinger.  Untersuch.  ueber  die  anomale  Kohlen  und  pigmentbildung. — • 
Eisenb. 

1823.  Halliday.     Lond.  Med.  Repos.     8vo. 

1824.  Cullen  (W.)  Carswell  (R.)  On  Melanosis,  (Edin.  Med.  Chir.  Trans.  voL 

i.)  Ed. 

1825.  Baillie.     Morbid.  Anat.  Edit.  Wardrop.     Lond.  . 

1826.  Fawdington,  (Th.)  A  case  of  Melanosis.     Lond.  8vo. 
1826.  Andral.     Diet,  de  Med.  (Art.  Melanose)  t.  14.     Par. 

1826.  Noack.     Comment,  de  Melan.  cum  in  hominibus  turn  in  equis.     Lips.  4to. 

1828.  Trousseau  &  Leblanc.     Archives  de  Med.     Juin. 

1829.  Andral.     Precis.  d'Anat.  Pathol,  t.  i.  p.  446.     Par. 

1830.  Crampton  (J.,  M.D.)  Case  of  Melanosis.   (Dub.  Med.  Trans.  N.  S.  vol.  i.) 

1831.  Gregory,  (J.  C.,  M.D.)  Case  of  black  infiltration  of  the  lungs.  (Ed.  Journ. 

vol.  36.  p.  339.)  Edin.  8vo. 
1833.  Williams  (D.,  M.D.)  Trans,  of  the  Provincial  Med.  Ass.  vol.  i.  Lond.  8vo. 

1833.  Hope  (J.,  M.D.)  Morbid  Anat.     Part.  II.  Lond.  8vo. 

1834.  Carswell,  (R.,  M.D.)  Pathological  Anatomy.     Fasc.  IV.  Lond.  fol. 
1834.  Carswell,  (R.,  M.D.)  Cyc.  of  Pract.  Med.  (Art.  Melanosis.)  vol.  iii.  Lond. 
Plates  representing   Melanosis. — Dr.  Carswell,  Pathol.  And.  Fasc.  IV.     Hope, 

Morbid  Anat.     Part.  II.     Fawdington,  Op.  Cit.     Williams,  Trans.  Provincial 
Ass.  vol.  i. —  Transl. 


424  ENCEPHALOID  TUMOR  OF  THE  LUNGS. 

founded  under  the  name  Scirrhus  Cancer.  It  is,  indeed,  the 
only  species  of  cancer  found  in  the  lungs  by  M.  Bayle  and  my- 
self. It  has  recieved  its  name  from  its  striking  resemblance  to 
brain.*  M.  Bayle  has  considered  this  disease  as  constituting  a 
variety  of  consumption,  and  has  named  it  Cancerous  Phthisis. 
I  will  not  here  detail  my  reasons  for  rejecting  this  species,  as  they 
are  nearly  the  same  as  already  adduced  against  the  admission  of 
the  Phthisis  with  Melanosis  of  the  same  author.  I  may  add, 
that  in  all  the  cases  which  I  have  met  with  of  medullary  sarcoma 
of  the  lungs,  death  has  been  produced  by  suffocation,  or  some 
other  affection,  before  the  period  when  any  thing  like  phthisical 
symptoms  could  have  been  produced.  And  I  am  of  opinion  that 
the  cases  of  this  cancer,  uncomplicated  with  tubercles,  detailed 
in  M.  Bayle's  work, — and  even  his  general  description  of  the  dis- 
ease,— tend  to  establish  the  same  conclusion.!     Medullary  cancer 

*  This  resemblance  is  not  so  strong  as  Laennec  affirms.  As  long  ns  the  en- 
cephalic matter  remains  hard,  nobody  would  confound  it  with  the  pulp  which 
constitutes  the  brain;  it  has  no  sort  of  analogy  to  it.  It  lias  a  little  more  resem- 
blance when  softened,  but  has  neither  its  texture  nor  shape ;  it  has,  however, 
in  a  certain  degree,  the  color  and  consistence  of  the  brain,  and  its  general  as- 
pect resembles  that  of  the  brain  of  a  foetus  already  softened  by  putrefaction. 

In  nearly  all  cases  of  encephaloid  of  the  lungs  which  I  have  ever  seen  CH 
heard  of,  this  accidental  production  existed  not  only  in  the  respiratory  apparatus, 
but  in  other  organs,  and  in  general  it  was  more  advanced  in  these  organs  than 
in  the  lungs.  It  was  not  in  the  lungs  that  the  encephaloid  had  disclosed  its 
existence  by  symptoms,  and  in  most  eases  the  existence  of  the  disease  in  the 
pulmonary  parenchyma  was  only  discoverable  after  death.  The  encephaloid 
therefore,  seems,  in  its  mode  of  attacking  the  organs,  to  proceed  in  a  manner 
the  reverse  of  that  of  tubercle.  In  fact,  tubercle  in  a  vast  majority  of  eases, 
first  appears  in  the  lungs,  and  from  thence  proceeds  to  invade  other  organs ;  the 
encephaloid,  on  the  contrary,  hardly  ever  fixes  itself  in  the  lung  till  afler  it  has 
been  developed  in  other  parts.  It  is  not  very  uncommon  to  see  the  pulmonary 
tissue  attacked  by  this  accidental  production  in  individuals  who  die  a  short  time 
after  undergoing  the  excission  of  a  cancerous  tumor,  from  the  body,  from  the 
mamma!  or  the  testicle,  for  example.  It  is  probable  that  in  the  greater  number 
of  cases  of  this  sort,  the  encephaloid  only  began  to  form  in  the  lung  after  the  ex- 
cission of  the  cancer,  as  if  the  cancerous  matter  no  longer  finding  a  place  of 
deposit  in  the  amputated  part,  took  to  other  organs,  which  perhaps  would  have 
remained  untouched,  had  the  primitive  causes  not  been  removed.  This  is  at 
least  one  of  the  methods  of  accounting  for  the  sudden  deaths  which  sometimes 
follow  the  excission  of  cancerous  tumor,  though  the  tumor  does  not  re-appear, 
I  will  add  that,  in  such  cases,  we  find  upon  dissection,  masses  of  encephaloid 
not  only  in  the  lungs,  but  in  most  of  the  internal  organs. — Andrul. 

1  The  encephaloid  matter  may,  while  it  spares  the  lungs,  be  produced  in  the 
thoracic  cavity  itself  in  considerable  masses  :  in  such  cases  the  anterior  medi- 
astinum is  the  more  frequent  place  of  deposit. 

Some  years  ago  I  saw  at  the  hospital  of  La  Charite  a  man  of  about  fifty,  who 
died  with  all  the  symptoms  of  cancer  of  the  stomach,  and  in  fact  had  the  dis- 
ease, as  appeared  upon  dissection  ;  but  in  addition  to  this,  in  lieu  of  the  cellular 
tissue  which  commonly,  in  an  adult  fills  up  the  space  between  the  two  pleurae 
behind  the  sternum,  there  was  found  a  cancerous  mass  which  had  not  affected 
in  any  degree  the  heart,  lungs,  or  sternum.  In  other  eases  which  have  been 
published,  the  cancerous  tumor  has  affected  some  of  the  adjacent  parts.  M. 
Bouillaud  quotes  a  case  of  this  sort  where  the  tumor,  pressing  upon  the  superior 
vena  cava  had  completely  obliterated  it.  [Art.  Cancer,  Diet.  Med.  et  Cliirug. 
pratique.] 


KNCKPHALOID  TUMOR  OF  THE  LUNGS. 


425 


may  exist  under  three  different  forms,  viz.  1st,  encysted;  2nd, 
in  irregular  masses,  without  a  cyst;  and,  3rd,  diffused  in  the 
tissue  of  an  organ.  In  whichever  of  these  forms  it  exists,  it 
presents,  in  its  progress,  three  different  and  distinct  stages, — viz. 
1st,  the  incipient  or  crude  state;  2nd,  its  perfect  state,  in  which 
it  exhibits  the  resemblance  to  brain,  which  forms  its  especial 
characteristic;  and  3d,  its  soft  or  dissolved  state.  I  shall  first 
describe  it  as  it  is  observed  in  the  second,  or  perfect  state,  as 
this  is  the  condition  in  which  the  three  varieties  most  nearly 
resemble  each  other,  there  being  much  difference  between  these 
in  their  first  and  last  stages.  In  its  perfect  state  it  is  homoge- 
neous, of  a  milky  white,  and  very  like  the  medullary  substance  of 

In  the  following  case,  a  cancer  also  in  the  anterior  mediastinum,  was  attended 
by  symptoms  resembling  those  of  an  aneurism  of  the  aorta.  This'  case,  pub- 
lished by  Dr.  Martin  Solon,  is  that  of  an  individual  aged  31,  who,  about  June, 
1830,  began  to  feel  pains  in  the  precordial  regions.  On  the  28th  July  he  was 
examined  for  the  first  time,  and  showed  the  following  symptoms: — Dullness  of 
the  precordial  region,  greater  and  more  extensive  than  in  the  normal  state; 
pains  caused  by  the  percussion  of  this  region  ;  souffle  and  bruit  cataire,  perceived 
by  auscultation  ;  no  difficulty  of  breathing.  Afterwards  the  dullness  extended, 
the  souffle  and  bruit  catairi  of  the  precordial  region  more  obscure  ;  the  respiration 
not  distinctly  heard  in  the  left  lung,  increased  evidence  of  the  existence  of  an 
aneurismal  tumor,  which  by  compressing  the  left  bronchus,  obstructs  the  en- 
trance of  the  air  into  the  lung  on  this  side.  Shortly  after,  neither  meat  nor 
drink  could  be  passed  into  the  aesophagus. 

In  the  beginning  of  September  the  countenance  of  the  patient  was  pale  and 
wan,  the  pulse  feeble  and  regular,  the  breathing  short  and  painful;  the  thorax 
was  dull  in  sound  throughout  its  whole  extent  except  the  right  lateral  portions; 
the  sounds  first  heard  by  auscultation  in  the  region  of  the  heart  were  no  longer 
perceptible.  The  patient  died  in  the  last  stage  of  marasmus,  unable  to  breathe 
or  swallow. 

Post  mortem  examination.  An  almost  total  dullness  of  the  chest ;  the  ante- 
rior mediastinum  was  occupied  by  a  cancerous  tumor,  weighing  nearly  three 
pounds,  and  shaped  much  like  a  heart  inverted  ;  its  longitudinal  diameter  was 
seven  or  eight  inches  ;  the  transversal  and  antero-posterior  six  to  seven.  The 
tumor  was  hard  in  some  parts,  and  soft  in  others,  and  exhibited  all  the  charac- 
teristics of  cerebriform  matter.  On  the  left,  it  strongly  compressed  the  left 
lung,  which  was  no  longer  permeable  to  the  air,  and  with  which  it  had  con- 
tracted adhesions.  On  the  right,  the  lung  was  slightly  forced  aside  towards 
the  ribs,  but  was  still  permeable  to  the  air.  The  posterior  surface  of  the  tumor 
was  united  to  the  pericardium,  and  had  caused  close  adhesions  between  this 
sack  and  the  anterior  face  and  edges  of  the  heart ;  the  posterior  face  of  the 
heart  was  free  from  adhesions.  The  heart  was  forced  toward  the  vertebral 
column,  and  was  only  two  thirds  the  size  of  that  of  an  adult.  The  parietes  of 
its  different  cavities  (ventricles  and  auricles)  were  very  thin.  In  no  other  organ 
was  there  any  mark  of  cancer. 

Another  case  of  cancer  of  the  anterior  mediastinum  was  observed  at  the 
Hotel  Dieu,  and  published  by  Dr.  Laberge.  This  case  in  which,  as  in  the  pre- 
ceding, symptoms  of  aneurism  of  the  aorta  were  discernible,  differs  from  that 
of  M.  Martin  Solon  in  this  particular,  that  the  cancer  extended  to  the  sternum, 
and  had  partly  destroyed  it.     The  patient  died  at  the  age  of  69. 

The  sternum  exhibited  on  its  external  face,  a  number  of  soft  depressible 
tumors,  which  rose  regularly  at  each  contraction  of  the  heart ;  in  compressing 
these,  the  finger  penetrated  through  the  sternum.  Behind  this  bone  was  found 
a  cancerous  mass,  very  similar  to  that  described  by  M.  Martin  Solon ;  but  in 
addition,  the  patient  had  cancerous  masses  in  the  stomach,  liver,  and  even  in 
the  peritoneum. — Andral. 

54 


426  ENCEPHALOID  TUMOR  OF  THE  LUNGS. 

the  brain.*  In  different  parts  it  has  commonly  a  slight  rose  tint. 
It  is  opaque  when  examined  in  mass,  but  in  thin  slices  it  is,  in  a 
slight  degree,  semi-transparent.  Its  consistence  is  like  that  of 
the  human  brain,  but  it  is  commonly  less  coherent,  being  more 
easily  broken  and  comminuted  by  the  finger.  According  to  its 
degrees  of  density,  it  resembles  one  part  of  the  brain  more  than 
another  ;  but  it  is  more  commonly  like  the  medullary  substance 
of  a  brain  that  is  more  than  ordinarily  soft,  (or  like  that  of  a 
child's,)  than  the  healthy  brain.  When  existing  in  any  conside- 
rable extent,  this  species  of  cancer  is,  in  general,  supplied  by  a 
great  many  blood-vessels,  the  trunks  of  which  ramify  on  the  ex- 
terior of  the  tumors,  or  between  their  lobes  only,  while  the 
minuter  branches  penetrate  the  substance  of  the  tumors.  The 
coats  of  these  blood-vessels  are  very  fine,  and  readily  ruptured ; 
and  this  accident  gives  rise  to  clots  of  extravasated  blood  in  the 
interior  of  the  tumors,  sometimes  of  considerable  size,  which 
bear,  occasionally,  a  slight  resemblance  to  those  found  in  the  brain 
of  subjects  dead  of  apoplexy.  Extravasations  of  this  kind  may 
sometimes  be  so  considerable  as  to  supplant  almost  the  whole  of 
the  brain-like  matter ;  so  that  the  true  nature  of  the  tumor  can 
only  be  ascertained  by  some  small  points,  still  remaining,  of  the 
original  growth.  This  change  occurring  in  superficial  tumors 
of  this  kind,  and  being  productive  of  much  haemorrhage,  appears 
to  me  to  have  given  rise  to  the  name  of  Fungus  Hcematodes,  ap- 
plied to  certain  cancers  by  modern  surgeons.  Under  this  name, 
however,  I  am  also  convinced  that  they  have  confounded  tumors 
of  different  kinds,  especially  those  commonly  called  varicose, 
which  are  composed  of  an  accidental  tissue  very  analogous  to  that 
of  the  corpus  cavernosum  penis.  I  have  never  observed  any 
lymphatics  in  tumors  of  this  sort,  but  it  is  probable  that  the 
circulating  system  is  complete  in  them,  as  I  have  seen  their  sub- 
stance deeply  tinged  with  yellow  in  cases  of  icterus.  The  matter 
of  encephaloid  does  not  continue  long  in  the  state  just  described  ; 
it  tends  incessantly  towards  a  softer  condition,  and  in  a  short 
space  its  consistence  scarcely  equals  that  of  a  thickish  paste. 
Then  begins  the  last  stage :  the  process  of  softening  becomes 
more  rapid,  until  the  morbid  matter  becomes  as  liquid  as  thick 
pus,  still,  however,  retaining  its  whitish  or  rosy-white  tint. 
Sometimes  at  this  period,  or  a  little  earlier,  the  blood  extravasa- 
ted from  the  vessels  contained  in  the  tumor,  becomes  intermixed 
with  the  morbid  matter,  so  as  to  give  it  a  dark  red  color,  and  the 
resemblance  of  clots  of  pure  blood.  In  a  short  time  the  extra- 
vasated blood  is  decomposed ;  the  fibrin  concretes,  and,  together 

*  The  English  have  also  named  this  morbid  production,  from  its  resemblance 
to  brain,  "Medullary  tumor."  They  recognized  it  as  a  distinct  disease,  with- 
out any  knowledge  of  what  had  been  done  in  France  .—Author. 


ENCEPHALOID    TUMOR    OF    THE    LUNGS. 


427 


with  the  coloring  matter,  unites  with  the  brain-like  matter  of  the 
tumor,  and  the  serum  is  absorbed.  In  this  condition  the  morbid 
growth  retains  no  resemblance  to  brain  ;  it  is  of  a  reddish  or 
blackish  color,  and  of  a  consistence  like  that  of  paste,  somewhat 
dry  and  friable.  Sometimes  the  change  of  structure  and  appear- 
ance is  so  complete,  that  one  would  be  led  to  consider  the  tu- 
mors as  of  a  different  kind,  but  for  the  existence  in  them  of  por- 
tions of  the  original  matter  still  unchanged.  In  some  cases,  con- 
temporaneously with  tumors  that  have  ^een  changed  in  this  man- 
ner, there  will  be  found  others  retaining  the  original  cerebral 
character;  so  that,  in  all  cases,  we  are  able,  with  a  little  practice, 
to  discover  the  true  nature  of  the  tumor  in  all  its  stages. 

Such  are  the  characters  which  this  species  of  cancer  presents 
in  its  two  latter  stages,  and  equally  in  all  the  three  varieties.  I 
shall  now  describe  the  characters  of  each  of  these  varieties  in  the 
first,  or  crude  state. 

1.  Encysted  medullary  tumor.  The  size  of  this  species  is 
very  various :  I  have  seen  the  tumors  as  small  as  a  hazel-nut, 
and  larger  than  a  middle-sized  apple  :  I  have  found  them  as  large 
as  this  in  the  lungs.  The  cysts  are  of  pretty  equable  thickness ; 
and  this  is  never  more  than  half  a  line ;  they  are  of  a  greyish- 
white,  silvery,  or  milky  color,  and  have  a  semi-transparency, 
more  or  less,  according  to  their  thickness.  Their  texture  is  alto- 
gether cartilaginous  and  rarely  fibrous ;  but  it  is  much  softer, 
and  less  easily  broken  by  bending,  than  cartilage  :  on  this  account 
they  must  be  ranged  among  the  imperfect  cartilages.  The  me- 
dullary matter  contained  in  these  cysts  can  be  easily  detached 
from  their  inner  coat.  It  is  commonly  divided  into  several  lobes 
by  a  very  fine  cellular  tissue,  which  may  be  compared  with  the 
pia  mater  ;  and  it  resembles  this  the  more  owing  to  the  great 
number  of  blood-vessels  which  traverse  it.  The  fineness  and 
brittleness  of  these  has  been  already  noticed,  and  also  their  pene- 
tration of  the  cerebriform  matter  itself,  to  which  they  give  a  rose 
tint,  here  and  there.  It  is  their  rupture  that  gives  rise  to  the 
clots  of  blood  formerly  mentioned.  Sometimes,  also,  the  trunks 
of  these  vessels  are  ruptured  in  the  interstices  of  the  lobules  ;  and 
the  blood  being  injected  beneath  the  fine  cellular  substance,  which 
accompanies  them,  gives  this  the  appearance  of  a  distinct  mem- 
brane. It  is  commonly  in  their  early  or  crude  stage  that  these 
tumors  are  divided  into  distinct  lobes.  These  are  especially 
observable  on  their  surfaces,  and  have  sometimes  considerable 
resemblance  to  the  convolutions  of  the  brain.  The  cyst  does  not 
at  all  enter  between  these  convolutions,  nor  does  it  even  indicate 
on  its  surface  their  place  or  configuration.  In  this  stage  the 
cerebriform  matter  is  pretty  firm,  often  firmer  than  the  fat  of 
bacon.     It  is  of  a  dull  white,  pearl-grey,  or  even  yellowish  co- 


428  ENCEPHALOID    TUMOR    OF    THE    LUM 

lor,  and,  in  thin  slices,  has  a  slight  degree  of  semi-transparency. 
When  cut  into,  it  appears  subdivided  interiorly  into  lobules 
much  smaller  than  those  seen  on  its  surface.  These  lobules  are 
in  such  close  contact  as  to  leave  no  interval  whatever  ;  and  their 
separation  is  merely  indicated  by  the  reddish  lines  traced  by  the 
vascular  cellular  tissue  by  which  the  separation  is  effected. 
These  lines  rarely  cross  each  other,  but  exhibit  many  irregular 
curves  and  convolutions.  When  the  tumors  pass  into  the  se- 
cond stage,  their  texture  becomes  more  homogeneous,  and  all  dis- 
tinction of  the  small  interior  lobules  is  quite  lost ;  the  distinction, 
however,  of  the  larger  exterior  lobes  still  continues.  The  blood- 
vessels which  run  between  these  lobes,  and  in  the  cellular  tissue 
immediately  investing  the  tumor,  are  much  more  developed 
than  in  the  early  stages  of  the  disease,  and  it  is  only  at  this  second 
stage,  or  as  it  approaches  the  third,  that  the  extravasations  of 
blood  take  place.  The  third  stage  begins,  as  I  have  already  men- 
tioned, when  the  medullary  matter  has  acquired  a  consistence 
like  pap  or  paste,  or  like  that  of  a  brain  softened  by  commencing 
putrefaction.  In  this  state  it  has  still  much  resemblance  to  cere- 
bral substance.  I  have  never  found  that  this  morbid  growth  sof- 
tens still  more,  or  that  it  is  absorbed  or  evacuated,  so  as  to  leave 
an  empty  cyst  or  cavity  like  tubercles ;  consequently  it  is  not 
probable  that  we  shall  ever  find  pectoriloquy  as  a  sign  of  this  af- 
fection. Hitherto  I  have  only  found  these  encysted  medullary 
tumors  in  the  lungs,  liver,  and  cellular  substance  of  the  medias- 
tinum. 

2.  Unencysted  medullary  tumor. — Medullary  tumors  of 
this  species  are  very  frequently  met  with.  Their  size  is  very 
variable ;  I  have  seen  them  from  the  size  of  the  head  of  a  full 
grown  foetus  to  that  of  a  hemp-seed.  Their  shape  is  commonly 
spheroid,  but  occasionally  flattened,  ovoid,  or  altogether  irreg- 
ular. Their  external  surface  is  lobulated,  but  the  divisions  are 
less  regular  than  in  the  encysted  species ;  their  internal  structure, 
in  the  two  last  stages,  is  precisely  the  same.  The  cellular  mem- 
brane which  invests  them,  is  more  or  less  marked,  according  as 
they  are  placed  in  a  loose  cellular  tissue,  or  in  the  substance  of  a 
viscus  of  firm  texture  ;  in  the  latter  case,  their  investing  mem- 
brane is  thinner  and  less  distinct.  In  their  first  or  crude  stage, 
their  semi-transparency  is  greater  than  afterward  ;  they  are 
almost  colorless,  or  have  a  very  slight  bluish  tint  in  occellated 
patches :  they  are  pretty  hard,  and  divided  into  numerous  lobes. 
Their  substance  is  then  fatty,  like  lard  ;  but  when  incised  it 
does  not  at  all  grease  the  scalpel,  and  heat  coagulates  by  it  with- 
out showing  a  particle  of  fat.  The  transition  from  the  first  to 
the  second  stage  takes  place  in  the  following  manner  : — the  sub- 
stance of  the  tumor  becomes  more  opaque,  softer,   whiter,  and 


ENCEPHALOID  TUMOR  OF  THE  LUNGS.  429 

its  inner  distinction  into  lobules,  for  the  most  part,  disappears. 
The  original  texture  is  observed  longest  in  the  neighborhood  of 
the  external  interlobular  fissures.  In  this  situation,  I  have  found 
portions  still  in  a  state  of  induration,  after  the  mass  of  the  tu- 
mors had  passed  into  the  third  stage.  I  am  led  to  conclude 
that  the  encysted  medullary  tumor  follows  precisely  the  same 
progress  as  that  just  described.  The  non-encysted  medullary 
tumors  may  exist  in  any  part  of  the  body  ;  but  they  are  most 
frequently  met  with  in  the  loose  and  abundant  cellular  tissue  of 
the  limbs,  and  in  the  larger  internal  cavities.  I  have  met  with 
them  in  the  cellular  membrane  of  the  fore-arm,  thigh,  neck,  and 
mediastinum ;  they  are  still  more  frequently  found  in  the  cel- 
lular substance  around  the  kidneys  and  the  interior  part  of  the 
spine,  and  in  these  situations  they  often  have  a  very  large  size. 
Although  they  are  frequently  found  in  the  viscera,  they  are, 
however,  much  rarer  there  than  in  the  cellular  substance. 

3.  Infiltration  of  organs  by  the  matter  of  medullary  tumor. 
— As  I  have  never  met  with  this  variety  in  the  lungs,  I  shall  not 
describe  it  in  this  place.  I  may  merely  observe  that  it  is  distin- 
guished from  the  unencysted  kind,  by  forming  masses  not  at  all 
circumscribed,  in  which  the  medullary  matter  approaches  nearer 
to  the  imperfect  or  crude  state,  the  more  distant  it  is  from  the 
centre  of  the  tumor.  It  exhibits,  moreover,  a  very  heterogeneous 
appearance,  produced  by  its  intermixture,  in  different  propor- 
tions, with  the  different  organic  tissues  amid  which  it  is  devel- 
oped.* 

During  the  greater  part  of  the  progress  of  Encephaloid  Can- 
cer, there  is  no  fever,  and  in  many  cases  it  proves  fatal  without 
having  even  occasioned  any  change  in  the  pulse.  When  fever 
makes  its  appearance,  it  is  commonly  owing   to  some   accidental 

*  The  anatomical  history  of  Encephaloid  Cancer,  as  given  by  Laennec,  has 
been,  like  that  of  Tubercle,  questioned  in  almost  every  particular.  According 
to  many  pathologists,  Scirrhus  and  Encephaloid  Cancer  are  not  accidental 
productions  or  tissues  of  new  formation,  developed  in  toto  wifhin  the  sub- 
stance of  other  organs,  and  preserving  a  sort  of  individual  and  peculiar  life. 
On  the  contrary,  they  are  regarded  as  mere  modifications  of  some  natural 
tissue,  the  cellular  or  cellulo-fibrous, — assuming  different  forms  according  to 
the  mode  in  which  the  particular  elementary  tissue  is  continued  in  the  com- 
position of  the  different  organs.  According  to  this  view,  Scirrhus  is  merely  an 
hypertrophy  of  the  cellular  tissue  carried  to  such  an  extent  that  all  the  cells  are 
obliterated  and  the  whole  mass  condensed  into  a  homogeneous  and  apparently 
lardaceous  substance.  Encephaloid  Cancer  is,  in  like  manner,  nothing  else  but 
the  same  cellular  tissue  more  or  less  hypertrophied  or  otherwise  altered,  and  into 
which  is  deposited,  by  a  true  morbid  secretion,  a  peculiar  inorganic  matter  hav- 
ing some  resemblance  to  the  substance  of  the  brain  :  this  matter  may  be  separat- 
ed from  its  investing  tissue  by  strong  pressure,  and  only  retains  an  appearance 
of  organization,  because  some  remains  of  the  cells  and  vessels  of  the  tissue  in 
which  it  is  deposited,  still  are  visible  amidst  its  mass.  Broussais,  Phleg.  Chron. 
t.  i.  p.  22,  et  seq. — Andral,  Clin.  Med.  t.  iv.  p.  404.  Cruveilhier,  Nouv.  Bib. 
Med.  Janv.  and  Fev.  1827.— (JW.  L.) 


430  ENCEPHALOID    TUMOR    OF    THE    LUNGS. 

circumstance,  as  when  the  tumor  presses  upon  any  important 
organ,  and  occasions  great  irritation  or  inflammation.  This  dis- 
ease may  also  exist  for  a  long  period  without  producing  emacia- 
tion ;  but  this  state  always  supervenes  before  death,  and  then 
makes  rapid  progress.  The  only  cases  in  which  death  supervenes 
without  previous  emaciation,  are  those  in  which  the  fatal  result  is 
immediately  owing  to  the  situation  of  the  tumors,  by  the  com- 
pression they  make  on  organs  essential  to  life,  as  the  brain  or 
lungs.  On  the  other  hand,  the  emaciation  begins  almost  as  early 
as  the  disease  itself,  in  certain  cases  where  the  affection  is  so  situ- 
ated as  to  be  capable  of  occasioning  a  colliquative  discharge,  as 
in  the  uterus.*  Dropsy  is  not  a  necessary  effect  of  this  disease, 
although  it  comes  on  very  frequently  towards  its  termination, 
particularly  if  it  is  situated  in  the  liver  or  womb.f 

From  the  preceding  account  it  results,  that  the  stethoscope 
ought  to  point  out  the  existence  of  the  medullary  tumor  of  the 
lungs,  when  this  is  of  considerable  extent.  In  the  work  of  M. 
Bayle  there  is  a  case  of  this  disease  in  the  lungs  (Case  XXXVI.) 
communicated  to  him  by  me.  I  shall  not  add  any  case  in  this 
place,  as  the  medullary  is  very  easily  distinguishable  from  every 
other  species  of  cancer.J 

*  It  appears  to  me  impossible  to  allow  that  the  cause  of  the  emaciation  which 
attends  cancer  of  the  uterus  should  be  sought  for  in  the  flux  accompanying  it, 
because  this  flux  is  often  inconsiderable;  the  emaciation  is  much  more  depend- 
ent on  the  disturbance  of  the  nutritive  process,  caused  by  the  great  alteration  of 
texture  which  the  uterus  undergoes. — Andral. 

t  The  dropsy  which  very  frequently  attends  cancer  of  the  liver  or  womb, 
does  not  depend  upon  the  mere  existence  of  the  cancerous  matter,  but  upon  the 
purely  mechanical  obstacle  encounterd  by  the  venous  blood,  in  its  return  toward 
the  heart. 

In  cancer  of  the  uterus,  the  dropsy  shows  itself  principally  in  the  lower  limbs, 
sometimes  in  one  and  sometimes  in  both,  and  it  may  almost  always  be  accounted 
for  by  the  compression  of  the  vessels  which  carry  the  blood  to  the  inferior  vena 
cava. 

In  cancer  of  the  liver,  the  dropsy  begins  almost  always  with  the  peritoneum, 
and  thence  extends  to  the  limbs.  It  arises  from  the  compression  exercised  by 
the  cancerous  masses  upon  the  ramifications  of  the  vena  porta.  Dropsy  is  not 
so  often  occasioned  by  cancer  of  the  liver  as  it  is  by  the  disorder  of  this  organ 
called  by  Laennec  cirrhose ;  and  the  alterations  of  the  liver  in  cancer  and  cir- 
rhose  account  plainly  for  the  difference  in  the  frequency  of  dropsy  between  the 
one  and  the  other  of  these  morbid  states. — Andral. 

X  The  disease  described  in  this  chapter  was  noticed  by  the  English  surgeons 
before  it  attracted  the  attention  of  our  author.  Their  researches,  however,  were 
entirely  unknown  to  him  when  he  first  published  his  account  of  this  disease.  It 
was  noticed  by  Dr.  Baillie  in  his  Morbid  Anatomy,  published  in  ]7!>0,  under  the 
name  of  the  pulpy  testicle;  but  it  was  Mr.  John  Burns,  of  Glasgow,  who  first 
called  the  attention  of  practitioners  to  this  affection,  under  the  name  of  spongoid 
inflammation,  in  his  Dissertations  on  Inflammation,  published  in  1800.  Mr. 
Hey,  of  Leeds,  without  any  knowledge  of  what  had  been  observed  by  Mr. 
Burns,  gave  an  account  of  the  same  disease  (which  he  termed  fungus  hcema- 
todes,)  in  his  Practical  Observations  in  Surgery,  published  in  1803 ;  and  in  the 
following  year,  (1804)  Mr.  Abernethy  described  the  affection  under  the  name 
of  medullary  sarcoma,  in  his  Surgical  Observations  on  Tumors.  But  the  com- 
pletes! and   best  account  of  this  disease  which   we  possess  in    the  English    Ian- 


431 


DISEASES    OF    THE    PULMONARY    VESSELS. 


CHAPTER  XTII. 


DISEASES    OF    THE     PULMONARY    VESSELS. 

Organic  lesions  of  the  vessels  of  the  lungs  are  extremely  rare. 
The  branches  of  the  pulmonary  artery  are,  no  doubt,  preserved 
from  aneurismatic  affections,  by  their  softness  and  elasticity ;  and 
I  have  never  seen  recorded,  nor  met  in  practice,  with  any  ex- 
amples of  ossification  in  them.  The  same  remark  applies  to 
the  bronchial  arteries,  which  are  perhaps  protected  from  both 
lesions  by  the  smallness  of  their  diameter.  The  pulmonary  veins 
seem  equally  exempt  from  organic  derangement.  I  have  never 
met  with  an  instance  of  the  varicose  state  of  them,  mentioned  by 
Riolan  and  two  or  three  other  observers.*  The  only  structural 
lesion  I  have  met  with  in  these  veins,  is  an  infarction  produced 
by  the  concretion  of  their  contents,  and  which  I  shall  notice  when 
treating  of  diseases  of  the  organs  of  circulation.  I  formerly  re- 
marked, that  the  vessels  of  different  orders,  particularly  the 
blood-vessels,  are  frequently  compressed  and  completely  flat- 
tened in  the  vicinity  of  tuberculous  masses  ;  and  the  same  re- 
mark may  be  extended  to  every  other  kind  of  engorgement  or  ob- 
struction of  the  pulmonary  substance.  In  hepatization  from  pneu- 
monia, and  even  in  the  haemoptysical  infarction,  when  it  has 
become  hard,  in  whichever  direction  we  lay  open  the  indurated 
portions,  we  find  only  very  few  vessels,  and  in  some  cases,  we 
cannot  observe  over  the  whole  extent  of  a  surface  of  several 
inches  square,  a  single  open  vessel.  In  these  cases,  injections 
thrown  into  the  pulmonary  artery  or  veins,  scarcely  penetrate 
the  hepatized  parts,  and  only  very  imperfectly  the  larger  trunks, 
as  has  been  remarked  by  M.  Cruveilhier.  I  had  formerly  occa- 
sion to  remark,  that  the  compression  of  the  vessels  produced  by 
the  tuberculous  infarction  of  the  lungs,  frequently  occasioned 
their  complete  obliteration,  either  within  the  bodies  of  the  tuber- 
culous masses,  or  on  the  walls  of  the  excavations  which  succeed 
these.  The  same  thing  must  happen  after  chronic  pneumonia, 
particularly  that  which  supervenes  to  gangrenous  eschars.     In- 

guagc,  is  contained  in  Mr.  Wardrop's  Observations  on  Fungus  Hamatodes  or 
Soft  Cancer,  published  in  1809.  In  this  work  the  author  notices  the  disease  as 
existing  in  most  of  the  organs  of  the  body.  In  1811  it  was  noticed  by  Dr.  Monro 
(Morbid  Anatomy  of  the  Gullet,  p.  1G0.)  under  the  name  of  milt-like  tumor  of  the 
mucous  membranes.  Since  then  the  periodical  publications  have  teemed  with 
cases  of  this  disease.  For  an  accurate  history  and  delineation  of  this  disease, 
see  Dr.  Cars  well 'a  Pathological  Anatomy,  Fasc.  ii.  and  iii. —  Transl. 

*  Srpulchret,  t.  ii.  sect.  iii.  obs.  vii.     Caldani  Memoire  di  Fisicu  del  soc.  Ital.  io. 
Modeoa,  torn.  .\ii.  part  second. — Hurlcs,  in  Ploucquet. 


432  OF    NERVOUS    AFFECTIONS    OF    THE    LtTNGS. 

deed,  in  this  case,  the  obliteration  of  the  greater  number  of  ves- 
sels is  quite  evident ;  and  I  formerly  remarked,  that  the  dryness 
of  the  part  affected,  is  one  of  the  essential  characters  of  this  or- 
ganic lesion.  The  pulmonary  vessels  are  likewise  more  or  less 
flattened,  when  the  lungs  are  compressed  against  the  spine,  by  a 
pleuritic  effusion,  but  in  this  case,  as  well  as  in  the  obstruction  of 
haemoptysis  and  acute  pneumonia,  when  the  compressing  cause  is 
removed,  the  blood  circulates  anew  in  its  wonted  channels,  there 
not  having  been  sufficient  time  to  cause  adhesion  of  the  sides  of 
the  vessels  to  each  other.  The  knowledge  of  this  state  of  com- 
pression of  the  pulmonary  vessels,  in  all  cases  of  pulmonary  ob- 
struction, ought  to  encourage  us  to  practice  the  operation  of 
empyema,  with  more  boldness  than  is  customary.  We  know  that 
it  has  more  than  once  happened,  that  the  surgeon,  after  pene- 
trating the  intercostal  muscles,  has  not  ventured  to  proceed  fur- 
ther, on  account  of  meeting  with  a  dense  substance,  which  he  has 
been  afraid  to  penetrate,  lest  it  might  be  the  lungs  themselves, 
but  which'  was  in  most  cases  merely  a  false  membrane.  Such  a 
doubt  will  hardly  be  entertained  at  present,  except  under  certain 
circumstances  which  are  extremely  uncommon,  as  will  be  shown 
in  the  chapter  on  pleurisy.  But  without  reference  to  these  signs, 
we  may  be  assured,  that  in  every  case  where  the  sound  of  respira- 
tion and  the  resonance  on  percussion  are  altogether  wanting,  and 
have  been  so  for  some  time,  in  one  side  of  the  chest,  there  is  no- 
thing to  dread  from  an  exploratory  puncture ;  when  these  two 
signs  are  present,  we  are  certain  that  there  exists  either  an  effusion 
into  the  pleura,  or  a  chronic  infarction  of  the  lungs  ;  in  the  first 
case,  the  operation  will  be  proper,  and  in  the  last,  we  need  be 
under  no  apprehension  of  any  dangerous  haemorrhage,  on  ac- 
count of  the  compression  of  the  pulmonary  vessels. 


CHAPTER  XIV. 

OF    NERVOUS    AFFECTIONS    OF    THE    LUNGS. 

Sect.  I. — Of  Neuralgia  of  the  lungs. 

Although  the  lungs  receive  a  great  many  filaments  from  the 
pneumo-gastric  nerve,  their  sensibility  of  relation  is  very  slight, 
even  in  a  state  of  disease.  In  the  most  acute  pneumonia  and 
haemoptysis,  the  pain  is  slight,  and  frequently  altogether  wanting, 
unless  the  pleura  be  at  the  same  time  affected ;  and  we  have 
shown  that  in   the  case  of  phthisis  and  catarrh,   the  patients  can 


OF    NEHVOUS    AFFECTIONS    OF    THE    LUNGS.  433 

rarely  point  out  the  spot  from  which  the  expectoration  proceeds. 
On  the  other  hand,  however,  it  is  by  no  means  rare  to  meet  with 
individuals  who,  without  any  physical  or  rational  sign  of  organic 
disease,  and  even  while  enjoying  the  most  perfect  health  in  other 
respects,  suffer  acute  pain,  sometimes  even  extremely  acute  pain, 
in  the  interior  of  the  chest.  This  pain  may  be  Momentary  or  of 
long  duration,  intermittent  or  continued,  confined  to  one  spot  or 
diffused,  fixed  or  movable ;  and  sometimes  it  shoots  by  fits  along 
the  walls  of  the  chest  and  neighboring  parts,  in  the  course  of 
the  intercostal  and  anterior  thoracic  nerve  or  the  brachial  plexus 
and  its  branches.  It  is  frequently  deep  between  the  spine  and 
scapula,  and  shoots  from  thence  in  such  directions  as  lead  to  the 
belief  that  it  is  situated  in  the  great  sympathetic.  I  have  been 
consulted  by  persons  who  suffered  from  pains  of  this  kind 
for  several  years ;  and  in  cases  where  they  were  of  recent  occur- 
rence, I  have  known  physicians,  otherwise  well  informed,  mistake 
them  as  indications  of  incipient  pneumonia  or  tubercles,  and  pre- 
scribe bloodletting,  with  the  effect  of  weakening  but  not  relieving 
their  patients.*  It  appears  to  me  evident,  that  these  disorders 
are  of  the  kind  to  which  we  give  the  name  neuralgia ;  a  class 
of  affections  which  unquestionably  have  their  site  in  the  nerves, 
since  the  pains  follow  the  course  of  these,  but  of  the  precise 
nature  of  which  we  are  ignorant.  In  these  cases,  dissection  has 
afforded  variable  results :  frequently  no  morbid  condition  of  the 
•  nerve  has  been  found :  sometimes  it  has  been  found  smaller,  at 
other  times  larger  than  natural.  In  some  rare  instances,  the 
neurilemma  has  appeared  red  from  injection  of  its  vessels,  or  sur- 
rounded with  a  transparent  jelly,  without  any  mark  of  inflam- 
mation, or  even  sometimes  (but  very  rarely  indeed)  infiltrated 
with  pus.  So  great  a  variety  of  appearances  ought,  I  think,  to 
lead  us  to  suppose,  that  these  may  be  the  consequence  and  not 
the  cause  of  the  ncuralgia.f 

*  I  allow  that  such  pains  cannot  be  purely  nervous  ;  but  they  also  often  exist 
in  cases  where  the  parenchyma  of  the  lungs  has  begun  to  contract  tubercles.  I 
have  seen  a  great  number  of  individuals  in  whom  the  first  pectoral  symptoms 
were  pains  either  deep  and  seeming  to  proceed  from  the  center  of  the  lungs,  or 
superficial  and  apparently  arising  from  the  pleura  :  these  patients  continued  to 
sutler  the  pain  for  a  longer  or  shorter  period,  and  the  desire  to  get  rid  of  it  was 
the  occasion  of  their  seeking  medical  aid.  Afterwards  they  began  to  cough  and 
feel  oppression  ;  by  degrees  they  became  phthisical. — Jlndral. 

t  There  is  one  kind  of  neuralgia  of  the  thoracic  parietes  which  I  have  very 
frequently  met  with  in  practice,  and  which.  I  believe,  is  often  mistaken  for  or- 
ganic disease  of  some  of  the  viscera  of  the  thorax  or  abdomen.  The  pain  is 
commonly  seated  about  the  middle  of  the  false  ribs;  it  is  frequently  of  long 
continuance,  and  is  often  very  distressing  to  the  patient,  but  rather  on  account 
of  its  obstinacy  than  violence.  It  is  observed  almost  always  in  young  women, 
and  is  in  most  cases  owing  (1  conceive)  to  pressure  upon  the  intercostal  nerve 
as  it  passes  from  the  spine.  I  have  adopted  this  opinion  from  having  found  it 
generally,  if  not  always,  connected  with  more  or  less  of  lateral  curvature  of  the 
.-pine,  and  from  having  seen  it  always  relieved,  and  often  entirely  removed,  by 

55 


434  OF    NERVOUS    AFFECTIONS    OP    THE    LUNGS. 

The  means  which  I  have  found  most  efficacious  against  these 
painful  affections  of  the  chest  are,  the  different  preparations  of 
mercury,  particuarly  frictions  with  corrosive  sublimate,  (from 
four  to  nine  grains  to  half  a  dram  of  lard.)  repeated  every 
second  day,  and  always  on  a  fresh  place.  These  frictions  I  have 
sometimes  continued  for  several  months  at  a  time :  and  when 
there  is  reason  for  fearing  that  this  preparation  may  be  too  irri- 
tating to  the  organs  of  digestion  or  respiration,  I  substitute 
calomel  in  a  like  dose.  I  have  also  sometimes  made  trial  of 
balsams,  particularly  copaiba,  and  turpentine  combined  with  the 
balsam  of  Tolu,  because  of  the  known  benefit  derived  from  these, 
in  large  doses,  in  other  cases  of  neuralgia,  particularly  sciatica. 
This  remedy  has  the  disadvantage  of  inducing  a  most  distressing 
hypercatharsis,  and  of  speedily  disgusting  the  patients,  if  they 
are  not  immediately  relieved.  When  the  pains  are  fixed,  I  have 
frequently  relieved  them  by  the  long-continued  application  of 
two  magnetized  plates,  disposed  in  such  a  manner  as  to  throw  the 
magnetic  current  existing  between  them  through  the  affected 
part.*     When  they  are  situated  in  the  intercostal  nerves,  and, 

means  directed  to  remedy  the  spinal  derangement.  For  a  further  account  of 
these  neuralgic  affections  of  the  lungs  and  other  viscera,  I  refer  the  reader  to  a 
Memoir  by  P.  Jolly,  M.  D.,  or  an  analysis  of  it  in  the  Med.  Chir.  Rev.  for  July, 
1828.—  Transl. 

No  doubt  that  after  a  neuralgia  which  has  caused  no  perceptible  lesion  in  the 
part  which  it  has  attacked,  divers  secondary  alterations  may  take  place  :  hyper- 
emia in  particular,  may  be  thus  "developed  in  consequence  of  the  great  augment- 
ation of  sensibility  in  an  organ.  The  following  is  a  striking  instance  lately 
witnessed  by  me.  A  female  who  had  been  subject  to  many  nervous  affections, 
was  in  June,  1836,  on  occasion  of  some  troubles  which  powcrfulljfc  affected  her, 
attacked  with  a  real  neuralgia  of  the  whole  of  the  skin.  She  seemed  in  every 
part  of  this  membrane,  to  be  constantly  pricked  with  thousands  of  needles;  the 
upper  surface  of  the  tongue  had  the  same  sensation.  At  intervals',  certain  parts 
of  the  skin  were  seized  with  a  pain  so  acute  as  to  extort  screams.  This  lasted 
some  minutes  at  the  highest  degree  of  intensity,  and  then  appeared  upon  these 
spots  a  violet  red  color,  with  a  remarkable  swelling  of  the  tissue.  This  species 
of  erythema  lasted  twelve  or  fifteen  minutes,  when  il  disappeared  gradually,  and 
from  the  moment  of  its  appearance  the  intensity  of  the  pain  abated.  This  re- 
markable affection  continued  about  twelve  days. — Judnil. 

*  The  recommendation  of  magnetism,  as  a  remedial  agent,  by  out  author, 
much  more  his  assertion  of  benefit  derived  from  it,  will  probably  be  met  by 
the  incredulity,  if  not  the  contempt,  of  most  English  lenders.  Although  not 
prepared  to  corroborate,  from  experience,  the  utility  of  this  practice,  I  am, 
nevertheless,  far  from  considering  it  as  unworthy  our  consideration,  much  less 
as  entitled  only  to  contempt,  as  the  offspring  and  pretence  of  quackery  and 
delusion.  The  close  analogy,  perhaps  we  might  say  identity,  of  this  power 
(more  particularly  as  it  relates  to  the  living  body)  with  electricity  and  galvan- 
ism, whose  influence  on  the  system  is  well  known,  and,  yet  more,  the  astonish- 
ing and  now  unquestioned  power  of  acupuncture  in  many  neuralgic  and  other 
diseases,  ought  to  make  us  hesitate  ere  we  reject  magnetism  as  a  remedial  agent, 
even  if  we  had  not  the  testimony  of  practical  men  in  favor  of  its  postitive  effi- 
cacy. See  the  Report  of  the  Commission  appointed  by  the  Royal  Society  of 
Medicine  of  Paris,  in  1775,  to  investigate  this  question,  published  in  the  me- 
moirs. 

Since  the  preceding  part  of  this  note  was  written,  (1827.)  magnetism  had  been 
employed  on  the  continent  and  in  England,  to  some  extent,  in  neuralgic  affec- 
tions, and  it  is  said  with  considerable  benefit.— Transl 


OF    NERVOUS    DYSPNffiA. 


435 


still  more,  in  those  branches  which  arise  from  the  brachial  and 
cervical  plexus,  and  are  distributed  over  the  fore  part ,  of  the 
chest,  the  application  of  a  perpetual  blister,  below  the  nipple,  or 
on  the  lower  part  of  the  sternum,  has  often  seemed  to  me  of 
benefit. 

We  must  be  careful  not  to  confound  these  neuralgic  affec- 
tions with  other  pains  which  are  clearly  sympathetic ;  such  as 
the  pains  of  the  back  so  common  in 'women  subject  to  leucor- 
rhaea ;  the  sharp  burning  pains  in  different  parts  of  the  chest, 
arising  from  indigestion,  flatulence,  &c.  ;  or  the  sensations  of 
roughness,  heat  or  oppression  beneath  the  sternum,  in  certain 
cases  of  catarrh. 

Sect.  II. — Of  Nervous  Dyspnoea. 

It  was  justly  remarked  by  Corvisart,  that  the  ancients  con- 
founded, under  the  name  of  Asthma,  several  varieties  of  dyspnoea 
arising  from  organic  diseases  of  different  kinds,  and  which  they 
very  improperly  considered  as  nervous  affections.  Those  va- 
rieties, in  particular,  which  depend  upon  organic  lesions  of  the 
heart  and  large  vessels,  had  especially  engaged  this  author's 
attention.  In  a  former  part  of  the  present  work,  I  have  shown, 
that  the  most  common  cause  of  dyspnoea,  when  of  sufficient 
severity  to  be  termed  asthma,  is  a  dry  catarrh,  latent  or  manifest, 
and  emphysema  of  the  lungs,  the  consequence  of  this.  (Edema 
of  the  lungs  may  also,  but  rarely,  have  so  slow  a  progress  as  to 
give  rise  to  similar  symptoms.  Effusions  into  the  cavity  of  the 
chest  can  hardly  be  enumerated  among  the  causes  which  occasion 
asthma ;  or,  at  least  the  difficulty  of  breathing  (often  extreme) 
produced  by  these,  could  not  be  confounded  with  the  spasmodic 
asthma  of  pathologists,  except  by  the  most  inattentive  and  unin- 
formed observer :  in  fact,  exclusively  of  the  phthisical  signs  of  the 
effusion,  the  progress  of  the  disease  in  this  case,  its  comparatively 
sudden  invasion,  and  its  duration,  (a  few  months  at  most,)  have 
nothing  in  common  with  the  insensible  development  and  chronic 
and  lengthened  course  of  nervous  asthma.  We  may,  in  like 
manner,  frequently  consider  as  originating  in  an  organic  source, 
the  breathlessness  which  often  accompanies  fits  of  apoplexy, 
epilepsy,  hysteria,  and  syncope  ;  since,  in  most  of  these  cases,  it 
is  evident  that  the  disorder  of  the  circulation  is  the  cause  of  that 
of  the  respiration,  and  that  this  last  is  occasioned  by  the  tem- 
porary congestion  of  blood  in  the  vessels  of  the  lungs. 

But  in  the  cases  now  under  consideration,  and  in  which  the 
dyspnoea  and  oppression  are  often  extreme,  we  have  frequently 
no  sign  whatever  of  vascular  congestion,  or  of  any  other 
organic   lesion  ;   and,   consequently,   we    must    attribute    them 


436  ASTHMA    WITH     PUERILE    RESPIRATION. 

to  disorder  of  the  nervous  influence  simply.  The  same  pro- 
position is  still  more  incontestable  in  many  other  instances. 
Many  persons  of  a  delicate  and  mobile  constitution,  cannot 
sustain  a  lively  emotion,  whether  from  physical  or  moral  causes, 
without  being  immediately  seized  with  intense  dyspnoea ;  and 
indeed  this  is  the  only  form  which  a  nervous  attack  assumes  in 
many  women.  Now,  in  cases  of  this  kind,  the  circulation  is 
frequently  not  at  all  affected. — The  dyspnoea  which  is  so  easily 
produced  by  the  slightest  exercise  in  very  fat  subjects,  is  also, 
in  great  part,  nervous,  and  must  be  chiefly  attributed  to  the 
great  expenditure  of  nervous  influence  required  to  move  a 
mass  so  disproportioned  to  the  ordinary  povyers  of  motion. 
In  this  case,  no  doubt,  the  acceleration  of  the  circulation  by  the 
bodily  exercise,  acts  as  an  accessory  cause  of  the  dyspnoea.-»-In 
some  rare  instances,  it  is  very  probable  that  dyspnoea  originates 
in  an  imperfect  paralysis  of  the  diaphragm  and  other  muscles  of 
inspiration,  that  is,  indeed,  self-evident  in  those  cases  of  palsy 
produced  by  compression  of  the  spinal  marrow  above  the  fourth 
cervical  vertebra  ;  and  we,  moreover,  now  and  then  meet  with 
pains  (usually  called  rheumatic)  in  the  thoracic  parietes,  which 
terminate  in  torpor,  as  in  cases  of  hemiplegia,  and  which  give 
rise  to  great  Oppression.  In  examples  of  impeded  respiration, 
whatever  was  its  cause,  I  have  frequently  seen  its  violence  les- 
sened (more  rarely  increased)  by  the  patient  merely  shutting  his 
eyes.  I  have  seen  the  same  thing  in  many  other  pains  in  dif- 
ferent parts  of  the  body,  and  particularly  in  pains  of  the  stomach 
and  intestines,  (so  intense  as  to  stimulate  those  of  inflammation,) 
which  the  patients  could  remove  or  induce  at  pleasure,  by  merely 
opening  or  closing  the  eyes,  or  by  turning  their  look  to  or  from 
a  bright  light.  In  such  cases,  it  is  evident  that  the  effects  can 
only  depend  on  the  stimulation  communicated  to  or  subtracted 
from  the  brain  by  the  light ;  and,  consequently,  that  disorder  of 
the  nervous  influence  simply,  without  any  organic  lesion,  may 
give  rise  to  dyspnoea,  as  well  as  other  nervous  affections. 

Among  the  instances  of  dyspnoea  of  sufficient  severity  and  per- 
manence to  merit  the  name  of  Asthma,  I  shall  notice  in  this  place 
two  kinds  to  which  we  cannot  assign  any  discoverable  organic 
lesion,  and  which  we  must  consequently  consider  as  nervous :  the 
first  of  these  I  shall  denominate  Asthma  with  puerile  respiration; 
the  other  is  the  common  Spasmodic  Asthma  of  practitioners. 

I. — Asthma  with  puerile  respiration. 

The  wants  of  the  system,  in  respect  of  respiration,  may  be  ex- 
actly measured  by  the  intensity  of  the  respiratory  sound.  I  have 
already  stated,  when  treating  of  the  exploration  of  the  respira- 


ASTHMA    WITH    PUERILE    RESPIRATION. 


437 


tion,  that  the  intensity  of  the  respiratory  sound  varies  much,  ac- 
cording to  many  circumstances,  and  particularly  according  to  the 
age  of  the  individual,  it  being  much  greater  in  infancy  than  in 
adult  life.  Whatever  be  the  cause  of  this  phenomenon,  there  is 
no  doubt  of  its  existence.  There  is  no  morbid  affection  which 
can  be  more  satisfactorily  referred  to  simple  disorder  of  the  ner- 
vous influence,  than  this  dyspnoea,  accompanied  with  puerile 
respiration,  and  which  I  formerly  alluded  to.  In  cases  of  this 
kind,  the  respiratory  sound  has  resumed  all  the  intensity  which  it 
possessed  in  early  infancy  ;  we  perceive  distinctly  the  pulmonary 
expansion  taking  place  with  uniformity,  completeness,  and  puerile 
promptitude,  in  all  the  air-cells  ;  and  yet  the  patient  is  oppressed 
in  his  breathing,  or,  in  other  words,  he  constantly  feels  the  want 
of  a  still  more  extensive  respiration  than  he  enjoys.  The  lungs, 
dilated  as  they  are,  in  an  extraordinary  manner  for  an  adult, 
nevertheless  have  not  capacity  enongh  to  satisfy  the  wants  of  the 
system.  This  affection  is  sufficiently  common  in  persons  affected 
with  chronic  mucous  catarrhs,  attended  by  a  [copious  and  easy  ex- 
pectoration. In  such  cases,  the  dyspnoea  is  frequently  very  in- 
tense, and  is  sometimes  so  aggravated  by  the  slightest  motion, 
that  the  patient,  though  otherwise  in  pretty  good  health,  is  con- 
demned to  a  life  of  inactivity,  or  even  to  an  almost  complete  state 
of  immobility.  Attacks  of  asthma,  however,  properly  so  called, 
are  less  frequent  in  such  subjects,  than  in  those  affected  with  the 
dry  catarrh.  In  these  latter  cases,  the  imperfection  and  small 
extent  of  the  respiration  easily  account  for  the  oppressed  breath- 
ing. But  in  the  others,  even  during  the  severest  attacks,  the 
completeness  with  which  the  respiration  is  performed,  is  quite 
astonishing  ;  the  sound  of  it  is  quite  puerile  ;  and,  as  in  the  case 
of  a  strong  and  healthy  child,  we  are  sensible  of  the  dilatation  of 
the  pulmonary  cells  to  their  full  capacity,  and  over  the  whole 
extent  of  the  chest.  Nevertheless,  the  patient  is  oppressed,  and, 
as  I  have  already  stated,  would  require  a  more  extensive  respi- 
ration than  his  organization  allows ;  in  other  words,  the  respira- 
tion is  very  perfect,  but  the  wants  of  the  system  in  relation  to  it 
are  increased  beyond  the  standard  of  health.  In  such  cases  it  is 
not  in  the  lungs  that  we  must  look  for  the  cause  of  the  disease, 
but  in  the  innervation  or  nervous  influence  itself;  and  this  will 
hold  equally  good,  even  if  we  adopt  the  chemical  theory  of  respi- 
ration, and  refer  the  dyspnoea  to  an  extraordinary  want  of  oxygen 
in  the  blood.  If  the  temporary  obstruction  of  the  bronchi  by  a 
little  mucus,  impedes  the  transmission  of  the  air  to  even  a  small 
portion  of  the  lungs,  the  patient  experiences  an  extreme  oppres- 
sion. Such  a  circumstance,  however,  is  uncommon  and  usually 
of  short  continuance,  since  the  expectoration  is  commonly  in  such 
cases  very  free.     I  have  never  met  with  this  species  of  asthma, 


438  SPASMODIC    ASTHMA. 

except  in  persons  affected  with  chronic  mucous  catarrh  ;  and,  in- 
deed, I  am  of  opinion  that  the  dyspnoea  arising  from  the  mere 
increase  of  the  natural  want  of  the  system  for  respiration,  can 
never  amount  to  asthma,  without  the  catarrhal  complication. 
This  want  of  the  system  for  respiration,  varies,  as  I  have  already 
said,  according  to  the  age,  and  also  in  individuals  of  the  same 
age.  The  adults  and  old  persons  who  have  puerile  respiration 
without  catarrh,  are  not,  properly  speaking,  asthmatic  ;  but  they 
are  short-breathed,  and  dyspnoea  is  induced  by  the  slightest  ex- 
ercise ;  though  when  sitting  still,  they  frequently  experience  no 
oppression  whatever.  The  dyspnoea  which  takes  place  in  some 
kinds  of  nervous  affections,  particularly  hysteria,  is  frequently  of 
the  kind  we  are  now  treating  of,  viz.  with  puerile  respiration. 
The  increase  of  the  necessity  for  respiration  is  not  confined  to 
the  cases  of  which  we  have  been  speaking ;  it  sometimes  also 
supervenes  in  cases  where  the  asthma  is  owing  to  other  causes. 
Thus  we  frequently  find  an  attack  of  asthma  begin  and  terminate, 
without  any  difference  in  the  state  of  the  respiratory  sound, — it 
being  equally  feeble  through  the  whole ;  and  in  such  cases,  where 
the  attack  is  not  occasioned  by  a  congestion  of  blood  in  the  lungs 
or  the  supervention  of  a  fresh  catarrh,  it  appears  to  me  that  the 
paroxysms  can  only  be  considered  as  a  temporary  augmentation  of 
the  want  of  the  system  for  respiration,  occasioned,  in  all  proba- 
bility, by  some  unknown  modification  of  the  nervous  influence. 

II. — Spasmodic  Asthma. 

In  the  infancy  of  pathological  anatomy,  every  kind  of  dyspnoea 
which  was  not  connected  with  an  evident  inflammatory  condition 
of  the  thoracic  organs,  was  considered  as  spasmodic  asthma. 
The  nosologists  of  the  last  century,  who  attempted  to  divide  dis- 
eases into  species  characterized  by  the  aggregation  of  their  symp- 
toms, and  more  especially  Sauvages  and  Cullen,  defined  asthma 
to  be — a  dyspnoea  recurring  in  paroxysms  after  intervals  in 
which  the  respiration  is  sometimes  quite  natural ;  each  paroxysm 
having  a  daily  aggravation,  coming  on  commonly  towards  even- 
ing or  at  night,  and  going  off  in  the  morning  with  a  more  or  less 
copious  expectoration.  In  the  present  day,  many  physicians 
among  those  who  have  most  cultivated  pathological  anatomy, 
formally  deny  the  possibility  of  a  spasmodic  dyspnoea,  and  this 
opinion  is  also  embraced  by  the  majority  of  the  remaining  prac- 
titioners. There  can  be  no  doubt  that  the  symptoms  just  men- 
tioned, are  met  with  in  many  cases  of  dyspnoea  which  evidently 
depend  on  organic  lesions, — particularly  chronic  catarrh,  whether 
dry,  pituitous,  or  mucous,  and  hypertrophy  or  dilatation  of  the 


SPASMODIC    ASTHMA. 


439 


heart.*  Sometimes,  also,  the  oppression  produced  by  effusion 
into  the  chest,  exhibits  a  well-marked  nocturnal  access.  With 
the  view  of  clearing  up  this  question,  I  shall  examine  it,  in  the 
first  place,  in  an  anatomical  and  physiological  point  of  view,  and 
shall  then  consider  the  facts  of  pathology  which  may  tend  to  set 
it  at  rest. 

Every  spasm  supposes,  at  least,  contraction  of  a  contractile 
organ :  this  is  what  is  called  tonic  spasm.  When  there  is  alter- 
nate contraction  and  relaxation,  the  spasm  is  called  clonic.  Some 
physiologists  are  further  of  opinion,  that,  in  certain  organs,  par- 
ticularly such  as  are  hollow,  the  contraction  does  not  alternate  a 
mere  relaxation  (the  consequence  of  an  intermission  in  the  con- 
tractile process,)  but  with  an  active  expansion  of  the  part.  Let 
us  now  enquire  whether  the  bronchi  and  air-cells  possess  either 
of  these  qualities. 

Reisseissen,  as  I  formerly  stated,  has  ascertained  the  existence 
of  a  set  of  completely  circular  fibres  around  the  bronchial  rami- 

*  To  the  numerous  lesions  giving  rise  to  asthma,  which  are  perceptible  on 
dissection,  the  German  physicians  have  added  another,  seated  in  the  thymus 
gland  :  they  describe  the  disease  arising  from  it  under  the  name  of  thymic 
asthma.  This  asthma,  according  to  them  is  occasioned  by  hypertrophy  of  the 
thymus  gland,  and  consequently  can  only  be  observed  in  early  infancy.  Drs. 
Kopp  and  Hirsch,  who  have  treated  particularly  of  this  disorder,  assign  for  its 
characteristic  symptom,  a  dyspnoea  in  the  form  of  fits,  during  which  there  is 
almost  a  suspension  of  breathing.  These  fits  occur  particularly  under  three 
principal  circumstances,  namely,  when  the  child  cries,  when  it  takes  food,  or 
at  the  instant  of  waking. 

The  thymic  asthma,  according  to  the  writers  who  have  described  it,  attacks 
children  from  the  age  of  three  weeks  to  that  of  eighteen  months:  most  com- 
monly it  begins  from  the  age  of  four  to  ten  months.  It  may  last  long,  gradually 
augment  in  intensity  and  prove  fatal.  When  it  terminates  favorably,  the  fits  grad- 
ually diminish  in  frequency  and  severity,  and  towards  the  age  of  four  years 
they  cease  altogether.  When  the  fit  comes  on,  the  child  suddenly  ceases  to 
breathe  :  it  is  evident  that  in  spite  of  their  efforts,  they  are  unable  for  some 
moments  to  pass  the  air  through  the  glottis  which  is  spasmodically  contracted. 
When  the  fit  is  not  so  violent  the  little  patient  continues  to  receive  the  air  into 
the  lungs,  but  in  an  imperfect  and  convulsive  manner  :  every  inspiration  is 
hissing,  very  short,  and  imperfectly  performed,  and  either  at  the  beginning  or 
end  of  the  fit,  that  is  to  say,  at  the  two  moments  when  it  is  least  evident,  it  is 
accompanied  by  a  sharp  cry  not  observed  in  any  other  malady,  and  which 
Dr.  Kopp  offers  to  our  notice  as  a  characteristic  sign.  During  the  fit  also  are 
remarked  all  the  signs  of  asphyxia  which  are  necessarily  connected  with  the 
suspension  of  the  breath.  In  the  intervals  of  the  fits,  the  children  appear  to 
enjoy  good  health,  are  lively  and  inclined  to  play.  They  die  often  in  a  fit ;  the 
malady  also  is  often  simple  at  the  beginning  and  afterwards  complicated  with 
epilepsy,  which  proves  fatal.  On  dissection,  the  thymus  gland  is  found  uncom- 
monly developed  both  in  length  and  breadth  :  it  compresses  and  forces  aside  the 
ud  the  different  organs  leading  to  them  or  to  the  heart.  Otherwise  the 
gland  shows  no  alteration  of  texture  or  sign  of  inflammation,  old  or  recent;  it  is 
merely  in  a  state  of  hypertrophy.  Minute  details  respecting  this  malady,  ex- 
tracted from  the  original  work,  may  be  found  in  the  Gazette  Medicale,  18?6, 
No.T.  I  think,  however,  that  the  statements  of  the  German  physicians  on  the 
subject  of  this  thymic  asthma,  are  not  to  be  admitted  without  a  certain  reserve  : 
they  require  to  be  authenticated  by  additional  researches  :  my  object  in  the 
present  note  has  been  merely  to  call  attention  to  this  point. — Andral. 


440  SPASMODIC    ASTHMA. 

fications,  beginning  at  the  point  where  the  cartilaginous  circles 
terminate.  I  also  mentioned  that  I  had  myself  verified  the  cor- 
rectness of  his  observation  upon  branches  of  less  than  a  line  in 
diameter ;  and  may  now  add,  that,  although  it  appear  to  be 
difficult  to  follow  to  a  greater  distance  the  muscular  fibres,  anal- 
ogy leads  us  to  admit  their  existence,  certainly  in  the  smaller 
branches,  and  perhaps  even  in  the  air-cells.  Taking  this  view  of 
the  subject,  it  is  very  conceivable  that  the  spasmodic  contraction 
of  these  fibres  may  be  carried  the  length  of  obstructing  the  air- 
passages  to  such  a  degree  as  to  prevent  the  transmission  of  air  to 
a  great  portion  of  the  lungs.  For  these  reasons,  we  cannot  re- 
gard the  tonic  spasm  of  the  bronchi,  or  even  perhaps  of  the  air- 
cells,  as  impossible ;  since  every  muscle  is  susceptible  of  spasm. 
Besides,  it  is  by  no  means  demonstrated,  that  muscular  fibre  is 
the  only  contractile  tissue ;  indeed,  the  contrary  is  proved  by  the 
fact,  that  animals  of  almost  a  mucilaginous  consistence,  are  ca- 
pable of  evident  contraction.  In  regard  to  expansion, — a  pheno- 
menon more  or  less  observable  in  several  organs,  such  as  the 
penis,  nipple,  heart,  retina,  uterus,  and  perhaps  even  in  the  cel- 
lular substance  and  the  brain, — its  mechanism  is  so  little  under- 
stood that  physiologists  have  been  forced  to  admit,  in  order  to 
explain  it,  a  vital  property  under  the  name  of  expansibility  or 
expansile  power.*  Without  investigating  the  probabilities  of 
this  theory,  I  shall  here  content  myself  with  enquiring,  as  a  mat- 
ter of  fact,  whether  the  lungs  are  capable  of  an  active  expansion, 
independently  of  that  which  they  undergo,  from  the  effects  of 
atmospheric  pressure,  in  following  the  dilatation  of  the  walls  of 
the  chest  during  inspiration.  If  we  lay  open  one  side  of  the 
chest  of  a  living  dog,  we  find  the  lung  at  first  reduced  to  one- 
fourth  of  its  former  dimensions ;  but  even  in  this  state  we  ob- 
serve it  swelling  and  contracting  with  an  alternate  motion.  This 
fact  was  noticed  by  M.  Roux,f  who  further  remarks,  that  we  can- 
not account  for  the  escape  of  a  portion  of  lung  in  the  case  of  a 
wound  of  the  chest,  but  by  an  active  expansion  of  the  viscus 
itself.  To  this  I  may  add,  that,  in  the  case  just  stated,  the  pro- 
truded portion  has  been  observed  to  be  dilated  during  inspiration, 
a  result  which  could  not,  under  such  circumstances,  be  occa- 
sioned by  the  pressure  of  the  atmosphere.  Another  argument  in 
favor  of  the  inherent  activity  of  the  lungs  is  furnished  by  the 
fact,  of  old  persons  being  still  able  to  breathe,  and  often  even 
without  any  previous  dyspnoea,  in  whom  the  cartilages  of  the  ribs 

*  Dr.  Prus  lias  attributed  this  property  to  many  other  organs  and  tissues,  and 
particularly  to  the  bronchi.  However  "much  disposed  to  adopt  this  opinion,  I 
cannot  regard  all  his  farts  as  probable1,  particularly  the  visible  dilatation  of  the 
bronchi,  which  I  formerly  stated  to  be  owing  to  mechanical  causes.  Dc  Vlrri- 
tation,  fyc.  par  V.  Prus,  M.D.  Paris,  1825.— Author. 

t  Melanges  de  Chir.  &c.  p.  87. 


SPASMODIC    ASTHMA. 


441 


are  ossified,  and  the  ribs  themselves  immovably  united  with  the 
vertebra.  In  such  cases  it  is  not  probable  that  the  diaphragm  is 
the  sole  agent  in  inspiration  and  expiration. 

The  study  of  respiration  by  means  of  auscultation,  furnishes 
us,  both  in  health  and  disease,  with  still  more  numerous  pheno- 
mena, which  leave  no  room  to  doubt  that  the  lungs  possess  an  in- 
herent power  of  action,  independently  of  the  other  powers  of 
inspiration  and  expiration.  It  was  formerly  stated — 1.  that  a 
hearthy  adult  cannot,  by  any  effort  of  inspiration,  give  the  puerile 
character  to  his  respiration ;  while,  on  the  other  hand,  this  char- 
acter returns,  even  during  the  slightest  inspirations,  when  a  great 
portion  of  the  lung  has  been  rendered  impermeable  by  some  orga- 
nic lesion  ; — 2.  that  a  forced  inspiration,  particularly  if  the  patient 
fancies  that  we  expect  him  to  breathe  in  an  extreme  degree,  gives 
hardly  any  sound  at  all,  and  is  consequently  very  incomplete ; 
and— 3,  that  the  convulsive  and  sibilous  inspiration  that  takes 
place  in  the  fits  of  hooping-cough,  is  not  accompanied  by  any 
sound  of  pulmonary  expansion,  and  appears  not  to  force  the  air 
into  the  air-cells.  I  have  observed  the  same  thing,  but  not  con- 
stantly, in  sobbing  and  yawning :  I  have  not  attended  to  the 
sound  of  respiration  in  sighing.  An  inspiration  made  inten- 
tionally, and  by  repeated  efforts,  without  any  intermediate  expi- 
ration, yields  very  little  sound,  or  none  at  all.  All  these  pheno- 
mena appear  to  me  inexplicable  without  admitting  an  inherent 
action  in  the  lungs.  We  cannot  comprehend  how  a  portion  of 
lung  can  regain  the  puerile  character  of  respiration,  unless  we 
admit  an  active  expansion  of  the  organ ;  for  we  know  that  this 
kind  of  respiration  is  not  accompanied,  at  least  not  constantly, 
by  a  more  extensive  inspiration  than  usual;  and,  moreover,  it 
frequently  happens  that  the  sound  of  respiration,  which  is 
frequently  scarcely  perceptible  in  such  inordinate  inspirations, 
becomes  immediately  afterwards  puerile,  during  much  feebler 
inspirations,  as  any  one  may  assure  himself  by  an  experiment 
which  I  shall  immediately  notice.  On  the  other  hand,  the 
great  inspirations  which  do  not  throw  the  air  into  the  air-cells, 
can  only  be  attributed  (except  in  cases  of  pulmonary  infarc- 
tion, not  now  under  consideration)  to  a  spasm  of  the  air-cells 
themselves,  or,  at  least,  of  the  smaller  bronchial  tubes.  I  had 
learned  by  experience  that  the  inspiration  which  precedes 
and  follows  coughing,  frequently  produces  a  pretty  strong 
respiratory  sound  in  persons  who  yield  hardly  any  during  a 
common  inspiration,  and  I  was  first  led  to  attribute  the  effect 
to  the  displacement  of  mucus  by  the  cough;  but  having  since 
observed  the  same  thing  in  individuals  who  did  not  cough, 
and  who,  in  the  intervals  of  the  attacks  of  asthma,  afforded 
no  symptoms  of  dry  catarrh,  I  began  to  suspect  that  the  phe- 
56 


442  SPASMODIC    ASTHMA. 

nomena  just  mentioned,  might  be  owing  to  a  spasm  of  the 
bronchi.  With  the  view  of  elucidating  this  point,  I  endea- 
vored to  produce  the  same  effects  by  augmenting  artificially 
the  necessity  for  respiration,  and  succeeded  perfectly.  Ac- 
cordingly, when  I  meet  with  a  patient  in  whom  the  respiratory 
sound  is  very  weak,  or  even  entirely  wanting,  in  more  or  fewer 
parts  of  the  chest,  without  there  being  any  sign  of  dry  catarrh 
or  other  organic  affection  which  could  produce  this  effect,  I 
desire  the  individual  to  read  aloud,  and  to  continue  to  do  so  as 
long  as  he  possibly  can,  without  drawing  his  breath,  and  when 
he  stops,  to  take  steadily  a  deep  inspiration.  Such  an  inspiration 
constantly  produces  a  well-marked  respiratory  sound,  and  some- 
times one  which  is  very  loud.  Moreover,  it  frequently  happens 
during  this  proceeding,  that  the  patient,  forgetting  the  recom- 
mendation given  him,  yields  unconsciously  to  the  necessity  of 
breathing,  in  the  middle  of  the  experiment,  and  takes  a  small 
furtive  inspiration.  And  it  frequently  happens  that  this  inspi- 
ration, short  as  it  is,  and  unaccompanied  by  any  perceptible 
elevation  of  the  walls  of  the  chest  or  abdomen,  produces  a  mo- 
mentary return  of  puerile  respiration,  in  the  very  points  in  which 
the  forced  inspirations  had  produced  no  respiratory  sound  at  all. 
In  the  case  of  persons  who  cannot  read,  we  may  make  the  same 
experiment,  by  getting  them  to  recite  something  which  they 
know  by  heart,  such  as  prayers ;  or  merely  by  causing  them  to 
retain  their  breath  as  long  as  they  possibly  can,  and  then  to 
breathe  at  their  ease.  These  facts  appear  to  me  inexplicable, 
except  by  the  admission  of  a  spasm  of  the  air-cells  and  small 
bronchial  tubes,  which  yields  momentarily  to  the  increased  ne- 
cessity of  breathing.  I  have  occasionally  explored  the  respiration 
of  fat  persons,  just  as  they  had  reached,  in  a  state  of  breathless- 
ness,  the  top  of  the  stairs ;  and  also  that  of  strong  healthy  young 
men  of  different  constitutions,  just  as  they  had  run  themselves 
out  of  breath.  In  both  these  cases,  I  find  the  respiratory 
sound  very  indistinct,  and  frequently  it  is  imperceptible  over 
the  greater  part  of  the  chest :  and  it  does  not  become  very 
distinct  until  after  the  individual  is  rested,  and  the  inspirations 
have  resumed  their  natural  frequency.  No  doubt,  in  these 
instances,  the  congestion  of  blood  which  takes  place  in  the 
lungs,  has  some  influence  in  producing  the  effects  witnessed : 
but  that  this  is  not  the  principal  cause  of  them,  is  proved  by  the 
chest  continuing  to  be  perfectly  sonorous.  From  these  experi- 
ments, and  those  formerly  related  when  treating  of  the  exploration 
of  the  respiration,  I  am  convinced,  not  only  that  the  air  cells  and 
the  bronchial  tubes  can  be  spasmodically  contracted,  but  even 
that  the  will  has  some  power  over  this  contraction.  This  seems 
proved  by  the  fact,  that  persons  in  perfect  health  can  make 
inspirations  which    give  rise    to  no  sound ;    and  indeed  this  is 


SPASMODIC    ASTHMA. 


443 


almost  invariably  the  case,  as  T  formerly  stated,  when  they  make 
an  extraordinary  effort  to  breathe  deep,  from  a  belief  that  we 
expect  something  very  unusual.  I  have  met  with  only  a  very 
small  number  of  asthmatics,  in  whom  there  was  evidence  of 
pulmonary  spasm,  without  any  attendant  catarrhal  affection ; 
but  some  few  I  have  met  with.  '  On  the  other  hand,  I  have 
known  a  great  number  of  patients,  in  whom  the  catarrh,  whether 
dry,  pituitous  or  mucous,  was  too  slight  in  degree  or  too  small 
in  extent,  to  be  considered  as  the  real  cause  of  their  asthma.  In 
several  of  these,  the  sound  on  percussion  was  not  good,  although 
there  was  no  sign  of  pulmonary  infarction  present ;  and  I  am 
much  disposed  to  believe  that  the  long-continued  contraction,  or 
at  least  moderate  distention  of  the  air  cells  may,  by  rendering 
the  pulmonary  tissue  more  compact,  produce  the  same  effect. — 
It  is  difficult  to  derive  from  morbid  anatomy  any  light  to  clear 
up  the  question.  An  attack'  of  purely  nervous  asthma  is  rarely 
fatal,  and  indeed  is  hardly  ever  so,  without  giving  rise  previously 
to  congestions  of  blood,  and  other  consequences  of  the  disorder 
of  the  respiration  and  circulation  induced  by  it ;  and  in  these 
consequences  prejudiced  minds  may  see  the  causes  of  the  disease. 
Some  cases,  however,  exist,  which  lead  irresistibly  to  the  belief 
of  the  possibility  of  an  asthma  purely  nervous.  I  do  not  speak 
of  cases  drawn  up  at  a  period  when  this  possibility  was  generally 
considered  as  amounting  to  an  incontestable  fact,  and  when  spas- 
modic asthma  was  reckoned  to  be  a  disease  very  common  and 
very  well  understood.  But  even  at  the  present  time,  when  the 
eyes  of  medical  men  are  particularly  directed  to  this  point,  and 
when  many  of  the  best  informed  members  of  the  profession  doubt 
whether  there  really  exists  any  severe  disease  depending  on  simple 
disturbance  of  the  nervous  influence  and  without  any  primary 
organic  lesion, — I  have  met  with  many  cases  in  which  it  was 
impossible,  after  the  most  minute  research,  to  find  any  organic 
lesion  whatsoever,  to  which  the  asthma  could  be  attributed.*     An 

*  I  do  not  deny  that  the  bronchi  in  their  minute  ramifications  may  contract 
or  dilate  in  an  active  manner.  Laennec's  observations  upon  this  point  are  well 
worthy  of  attention,  and  very  plausible  ;  but  I  think  it  important  to  remark 
here,  that  the  existence  of  the  nervous  dyspnoea  does  not  depend  upon  a  spasm 
ill  the  coats  of  the  bronchial  tubes  or  the  vesicles  to  which  they  lead.  To 
allow  the  possibility  of  nervous  dyspnoea,  we  have  only  to  bear  in  mind  that 
physiological  research  has  shown  the  influence  which  in  a  normal  state,  the 
nervous  system  exercises  over  the  functions  of  the  lungs.  A  disturbance  of 
this  system  may  obstruct  the  transformation  of  the  venous  into  arterial  blood. 
Now,  whenever  this  obstruction  happens,  the  respiration  must  quicken  instinc- 
tively, and  by  consequence,  give  rise  to  dyspnoea. 

If  from  this  theoretical  view  we  descend  to  facts,  it  will  be  impossible  to 
deny  the  existence  of  a  great  number  of  cases  where  the  breathing  becomes 
difficult,  without  any  possibility  of  accounting  for  it  by  any  of  the  lesions  per- 
ceptible on  dissection,  to  Which  the  authors  who  deny  the  dyspnoea  called 
nervous,  always  endeavor  to  ascribe  asthma.  In  fact,  what  physician  has  not 
witnessed  cases  of  difficulty  of  breathing,  sometimes  very  painful,  either  con- 
tinual or  recurring  at  intervals,  in  young  and  plethoric  subjects,  who  otherwise 


444  SPASMODIC    ASTHMA. 

instance  of  the  same  kind  is  given  by  M.  Andral  (CI.  Med.  t.  ii. 
ob.  xx.)  in  the  case  of  a  fatal  suffocation  supervening  to  the  sup- 
pression of  a  discharge  from  an  ulcerated  leg.  The  lungs  in  this 
case  were  sound,  except  that  there  existed  in  the  left  lower  lobe 
a  small  hepatized  point,  of  less  extent  that  the  tenth  part  of  the 
lobe  (pneumonia  of  the  dying,  according  to  all  appearances.) 
The  heart  and  the  other  organs  were  equally  sound.  M.  Guer- 
sent  has  likewise  seen  two  children  die,  after  a  few  days,  of  a 
remitting  dyspnoea,  attended  with  dry  cough  and  precordial 
anxiety,  in  whose  bodies  no  obvious  lesion  could  be  found  after 
death.  (Diet,  de  Med.  t.  hi.  p.  126.)  I  am  convinced  that  in 
the  greater  number  of  asthmatic  cases,  depending  on  dry  catarrh 
and  pulmonary  emphysema,  the  asthmatic  paroxysm  can  be  in- 
duced equally  by  the  supervention  of  a  fresh  catarrh  (latent  or 
manifest)  and  by  a  deranged  state  of  the  nervous  influence,  occa- 
sioning pulmonary  spasm  or  an  increase  of  the  necessity  of  res- 
piration, and  sometimes  by  both  causes  at  once.  In  fact,  I 
believe  there  are  few  cases  of  asthma  owing  to  any  one  of  these 
causes ;  and  in  old  men  more    particularly,  I  imagine  that  several 

show  no  symptom  of  organic  affection,  either  of  the  lungs  or  heart?  This 
dyspncea  very  often  accompanies  a  state  of  general  hyperemia.  It  frequently 
occurs  in  females  who  suffer  from  plethora  and  irregular  menstruation  :  it  also 
happens  in  young  men  a  little  before  or  after  the  period  of  puberty.  It  would 
appear  that,  in  consequence  of  a  too  rich  supply  of  blood  passing  through  the 
lungs,  it  becomes  necessary  that  more  air  than  common  should  be  brought  in 
contact  with  it  in  a  given  time  ;  hence  arises  the  feeling  of  dyspncea.  Blood- 
letting, or  what  amounts  to  the  same  thing  in  such  cases,  a  less  substantial  regi- 
men, and  more  exercise,  which  causes  a  greater  expense  of  blood,  commonly 
suffice  to  restore  the  breathing  to  its  natural  freedom. 

There  are  other  sorts  of  dyspnoea,  caused,  on  the  contrary,  by  blood  too  thin, 
as  may  be  exemplified  daily  in  cases  of  anemia  and  chlorosis.  The  mechanism 
may  be  understood  as  easily  as  in  the  foregoing  case  :  here  the  blood  no  longer 
furnishes  the  air  with  the  materials  necessary  for  a  perfect  sanguification,  and 
the  suffering  of  the  whole  system  displays  itself  in  the  dyspnoea.  This  also 
appears  to  be  the  cause  of  the  difficulty  of  breathing  experienced  by  scorbutic 
subjects  at  an  advanced  period  of  their  disease.  Finally,  we  see  cases  where 
the  difficulty  of  breathing  evidently  arises  from  a  primitive  trouble  in  the  nervous 
system,  without  any  attendant  change  in  the  composition  of  the  blood.  I  have 
known,  for  example,  a  man  of  great  nervous  sensibility,  who  could  never  witness 
another  person  suffering  dyspnoea,  without  at  the  same  time  being  painfully 
affected  the  same  way  himself;  in  other  respects  this  person  showed  no  signs 
of  pulmonary  affection.  Strong  mental  agitation  often  causes*  an  instantaneous 
oppression  of  breathing,  which  continues  afterwards  for  a  longer  or  shorter  time. 
Hysterical  females,  as  Laennec  remarks,  often  have  fits  of  suffocation  among  other 
symptoms,  which  give  evidence  of  a  great  trouble  in  the  nervous  system.  In 
short,  I  have  many  times  been  consulted  by  individuals,  informing  me  that  they 
had  been  attacked  at  intervals,  on  occasion  of  violent  emotion  or  without  any 
perceptible  cause,  by  an  extreme  difficulty  of  breathing,  with  a  feeling  of  inex- 
pressible anguish  and  a  painful  constriction  of  the  chest,  &c.  This  condition 
lasted  some  hours,  during  which  the  patient  expected  to  die  for  want  of  breath  ; 
it  ceased  either  by  degivcs  or  suddenly,  and  the  patients  were  restored  to  full 
health.  In  the  intervals,  they  had  no  cough  nor  felt  any  difficulty  of  respira- 
tion. I  have  examined  these  individuals  with  great  attention,  and  found  no 
trace  of  any  affection  either  of  the  heart,  or  large  vessels,  or  the  respiratory 
apparatus,  or  emphysema  of  the  lungs.—  Andral 


SPASMODIC    ASTHMA.  445 

frequently  conspire  to  produce  the  result.     Of  this  kind  are,  de- 
bility, the  ossification  of  the  cartilages  and  immobility  of  the  ribs, 
rheumatism  affecting  the  walls  of  the  chest,  and  perhaps  also  the 
tenuity  of  the  air-cells   and  of  all  the  pulmonary  vessels,  in  ad- 
vanced life.     With  the  exception  of  the  different  kinds  of  catarrh, 
the  occasional  causes  of  attacks  of  asthma  and  dyspnoea  are  almost 
always  of  a  kind   to  give  occasion   to  an    immediate  and  evident 
disturbance  of  the  nervous  influence.     Of  this  kind  are,  strong 
mental  emotion ;  venereal  excesses ;  the  influence  of  light  or  dark- 
ness ;  retrocession  of  gout   (an  affection   which,  from   its  mobility 
and  various  effects,  can  only  be  considered  as  a  nervous  affection ;) 
certain    odors,   such    as    those    of   tuberose,    heliotrope,    stored 
apples,  &c. ;    changes  of  the  atmospheric   electricity,  and   other 
less   appreciable   conditions  of  the   atmosphere.     We  thus  find 
that  the  greater  number  of  asthmatic  patients  cannot  remain  with 
impunity  in  a  low  close   apartment,  although  containing  much 
more  air  than  they  could   consume  in    twenty-four   hours,  and 
although   it  is   constantly  but  insensibly  renewed   by  the  doors 
and  chimneys.     Some  cannot  bear,  without  experiencing  a  feeling 
of  suffocation,  that  any  person    should  go  before   them,  or  that 
any  thing  should  be  brought  close  to  them ;  while  others,  on  the 
contrary,  are  never   more  subject  to   dyspnoea  than  when    in  the 
midst  of  a  vast  plain.     The  following  fact,  communicated   to  me 
by  one  of  my  colleagues,  affords  a  curious  example  of  a  nervous 
affection  of  a  similar  kind,  in  a  person  not  subject  to  asthma. 
A  man  forty  years  of  age,  slightly  hypochondriacal,  but  otherwise 
in  good    health,  wished    to  go  on  horseback   to  pay  a  visit  some 
leagues  distant  from  his  house.       As  soon  as  he  left  the  town 
where  he  resided,  which  is  situated  in  an  extensive  plain,  he  felt 
an  immediate  oppression  on  the  chest  from  the  impression  of  the 
country  air.     He  took  no  notice  of  this  at  first ;  but  the  dyspnoea 
having  greatly  increased,  and  being  now  attended  by  a  sense  of 
faintness,  he   determined  to  return.     He  had  scarcely  turned  his 
horse,   when  he   found  himself  better ;  and  in  a   few  minutes  he 
recovered  both  his  breath  and  his  strength.     Not  suspecting  any 
relation  between  this  momentary  uneasiness  and  his  journey,  he 
once  more  attempted  to  advance,  and  was  again  soon  attacked 
with  the    dyspnoea  and   faintness.     On  turning  towards  the  town 
these  passed  off.     After  having  made    repeated  attempts  to  pro- 
ceed,  and  always  with  the  same  result,  he  finally  returned,  and 
in  just  as  good   health  as  when  he   set  out.     I  lately  met   with  a 
case  very  analogous  to  the  one  just  related,  only  that  in  this,  the 
symptoms  were  more  severe,  and  the  cause  different,  being  the 
want  of  light  and  a  free  circulation  of  air.     Count  H.,  a   man  of 
a  robust  constitution,  and  although   now  eighty-two  years  of  age, 
still  possessed  of  a  degree  of  vigor   unusual   even  at   the  age  of 


44(>  SPASMODIC    ASTHMA. 

sixty,  has  been  subject  from  his  infancy  to  attacks  of  asthma, 
and  is  habitually  somewhat  short  breathed.  Since  his  fiftieth 
year  he  has  had  a  slight  cough,  and,  in  the  morning,  a  pituitous 
expectoration  intermixed  occasionally  with  some  yellow  sputa. 
The  asthmatic  attacks  have  always  been  infrequent  with  him ; 
but  they  have  invariably  come  on  if  any  person  has  inadvertently 
shut  his  bed-room  door,  or  if  his  night  lamp  has  by  any  chance 
gone  out.  As  soon  as  either  of  these  accidents  occurs,  he  im- 
mediately awakes  with  a  feeling  of  oppressive  suffocation,  and 
after  a  few  minutes  becomes  insensible.  I  have  explored  the 
chest  of  this  patient,  and  have  only  detected  some  signs  of  a 
slight  pituitous  catarrh ;  the  sound  of  respiration  is  middling,  as 
it  ought  to  be  in  the  adult,  and  is  intermixed,  in  a  few  points 
only  of  small  extent,  with  a  slight  sibilous  or  mucous  rhonchus. 
On  the  occasions  alluded  to,  the  attack  is  got  rid  of  by  opening 
the  doors  and  windows,  lighting  the  candles,  and  carrying  the 
patient  into  the  open  air  ;  but  the  oppression  remains,  in  a  cer- 
tain degree,  for  several  hours. 

The  volatilized  oxyds  of  lead,  the  effects  of  which  on  the 
nervous  system  are  incontestable,  frequently  give  occasion  to 
asthma,  as  has  been  remarked  by  many  authors  both  ancient  and 
modern,  (Ploucquet,  Art.  dyspncea).  It  is  moreover  worthy  of 
remark,  that  most  fits  of  asthma  are  accompanied  by  an  extra- 
ordinary accumulation  of  gas  in  the  intestines,  a  circumstance 
which  is  equally  observable  in  other  nervous  affections.  Other 
nervous  symptoms,  of  greater  or  less  severity,  and  more  especially 
convulsive  motions  in  various  parts  of  the  body,  are  likewise 
frequent  attendants  on  asthma.  Furthermore,  if  we  carefully 
study,  and  for  a  certain  length  of  time,  the  dry  catarrhs,  whether 
latent  or  manifest,  which  almost  always  accompany  hypochon- 
driasis and  continued  fevers,  we  shall  find  that  the  organic  dis- 
ease is  under  the  direct  influence  of  the  nervous  affection,  and  is, 
indeed,  probably  produced  by  this  ;  since  we  find  that  it  (the 
catarrh)  is  increased  as  often  as  the  deranged  condition  of  the 
nervous  influence  is  augmented  by  a  lively  emotion  or  by  any 
other  cause.  From  all  these  facts  and  considerations,  I  think  I 
am  entitled  to  conclude,  that  the  greater  number  of  asthmatic 
paroxysms,  although  depending  on  several  causes  combined,  are 
chiefly  induced  by  a  primary  and  momentary  alteration  in  the 
state  of  the  nervous  influence.* 

*  In  the  article  Jlsthma  of  the  Cyclopaedia  of  Practical  Medicine,  I  have  given 
a  pretty  full  view  of  the  history  of  the  disease  here  treated  of  hy  Laennec,  and 
to  this  I  must  refer  the  reader  for  more  particular  information.  The  following 
brief  extracts  will  point  out  the  distinctions  which  reasoning  and  observation 
have  led  me  to  adopt,  in  regard  to  the  varieties  of  asthma.  I  will  merely  pre- 
mise that  I  consider  the  arguments  in  the  text  (and  many  others  might  be  addu- 


SPASMODIC    ASTHMA. 


447 


Treatment.  Since  as  I  have  just  said,  the  periodic  asthma 
commonly  depends  on  the  re-union  of  several  organic  and  nervous 

ced)  as  sufficient  to  prove  the  existence  of  a  nervous  asthma  properly  so  called, 
th;U  is,  an  asthma  unattended  by  any  organic  lesion  of  the  thoracic  viscera. 

"  It  must  not  he  imagined  that  we  consider  the  asthmatic  paroxysm  as  consist- 
ing exclusively  of  a  muscular  spasm  of  parts  otherwise  healthy.  This,  indeed, 
may  he  the  case  in  a  few  instances  ;  but  it  is  not  to  be  doubted  that,  in  the  great 
majority  of  cases,  the  spasm  not  merely  affects  parts  previously  diseased,  but 
that  the  phenomena  of  the  paroxysm  are  partly  dependent  on,  and  greatly  modi- 
fied by,  these  very  lesions  co-existing  with  the  spasm,  aggravating  it,  and,  in 
turn,  being  aggravated  by  it.  .  .  .  We  shall  divide  cases  of  asthma  into  two  clas- 
ses or  groups,  according  as  there  exists  a  sound  or  a  diseased  state  of  the  bronchi- 
al membrane  in  the  intervals  of  the  paroxysms  ;  terming  those  of  the  first  class 
nervous  asl/una,  and  those  of  the  second  catarrhal  asthma. 

I.  Nervous  asthma. — The  characteristic  quality,  or,  at  least,  the  most  manifest 
physiological  peculiarity  of  the  individuals  subject  to  nervous  asthma,  is  the  ex- 
treme susceptibility  of  their  nervous  system.  They  are  said,  in  common  lan- 
guage, to  be  nervous,  or  to  possess  the  nervous  temperament.  This  is  the  asth- 
ma of  hysterical  females,  and  is  indeed,  in  many  cases,  only  one  of  the  multi- 
form aspects  of  hysteria.  It,  however,  occurs  equally  in  males,  and  in  females 
who  have  no  other  symptom  of  hysteria. 

For  the  sake  of  those  who  are  curious  in  nosological  arrangements,  rather  than 
as  being  of  any  practical  value,  the  following  classification  of  the  various  cases 
which  come  under  the  head  of  nervous  asthma  is  submitted  to  the  reader. 

1.  In  a  very  small  proportion  of  these  cases  we  cannot  detect  any  disorder  of 
the  system,  general  or  local,  which  can  be  considered  as  at  all  influencing  the 
occurrence  of  the  paroxysms.  These  may  be  termed  cases  of  pure  nervous  asth- 
ma. 

2.  In  an  infinitely  larger  proportion  of  cases  we  find  more  or  less  of  disease  in 
the  system  generally,  or  in  some  of  the  principal  organs  ;  and  which  disease  ap- 
pears to  be  the  remote  cause  of  the  paroxysms,  influencing  the  bronchial  muscles 
indirectly  through  the  intermedium  of  the  brain.  Such  cases  may  be  termed 
sympathetic  nervous  asthma.  This  order  may  be  subdivided  into  species,  accord- 
ing to  the  nature  or  site  of  the  affection  which  constitutes  the  remote  cause  of 
the  paroxysm. 

3.  In  a  third  group  may  be  included,  under  the  name  of  sympathetic  nervous 
asthma,  1,  those  cases  which  depend  on  diseases  immediately  affecting  the  pul- 
monary nerves  themselves,  and  2,  those  in  which  the  paroxysms  are  directly  in- 
duced by  organic  disease  of  the  lungs,  head,  pleura,  &c. 

II.  Catarrhal  asthma. — In  studying  the  various  cases  of  asthma  met  with  in 
practice,  while  we  find,  in  the  vast  majority  of  instances,  some  fixed  affection  of 
the  bronchial  membrane,  we  find  great  variety  in  the  nature,  and  still  more  in 
the  degree  of  this  affection.  In  one  class  of  cases  there  seems  to  be  merely 
some  peculiar  modification  of  the  sensibility  of  the  bronchial  membrane,  which 
renders  it  susceptible  of  being  excited  to  morbid  action  by  various  external 
influences.  In  others,  however,  and  in  an  infinitely  larger  number,  there  exists 
cither  an  habitual  catarrh  of  a  formal  character,  or  such  a  predisposition  to  be 
affected  by  catarrh,  as  practically  to  amount  to  a  like  condition  of  the  parts.  .  .  . 
Sooner  or  later,  and  generally  very  soon,  the  mucous  membrane  becomes  disor- 
dered permanently  ;  and  it  is  this  local  disease  of  the  lining  membrane  of  the 
air-passages,  together  with  the  general  liability  to  be  affected  by  slight  degrees 
of  cold,  which  constitutes  the  most  common  state  of  persons  subject  to  asthma. 
Between  the  extreme  limits  of  this  bronchial  affection,  from  mere  increase  of 
sensibility  up  to  the  most  acute  inflammation,  the  degrees  of  shades  are  infinite. 
The  catarrhal  affections  with  which  the  asthmatic  spasm  may  be  cpmbined 
may  be  either  (a)  acute  or  (b)  chronic.  Of  these  the  chronic  varieties  are  by 
far  the  most  common. 

A.  1.  The  first  variety  of  the  chronic  catarrhal  asthma  is  ranged  under  the 
present  head  more  from  analogy  than  from  any  certain  proof  of  its  being  essential- 
ly of  a  catarrhal  nature.  Its  essential  characteristic  seems  to  be  a  peculiar  mor- 
bid sensibility,  or  irritability  of  the  membrane  lining  the  bronchi,  rather  than. 


448  SPASMODIC    ASTHMA. 

affections,  it  is  necessary  in  every  case  to  study  with  care  all  the 
elements  of  the  disease,  as  it  is  this  study  only  that  can  lead  us  to 

any  sensible  physical  alteration  of  it.     If  a  name  is  desired  for  it,  it  miplit.  u; 

the  language  of  Laennec,  be  termed  latent  catarrhal  asthma This  peculiar 

irritability  of  membrane  in  many  cases  continues  perfectly  latent  until  rendered 
manifest  by  the  application  of  certain  stimulants.  Some  individuals  arc  affected 
by  only  one  kind  of  substance,  others  by  two  or  more.  Ipecacuanha  seems  the 
substance  which,  of  all  others,  exerts  the  geatesi  influence  in  cases  of  this  kind. 

2.  The  next  variety  of  chronic  catarrhal  asthma  is  that  which  is  complicated 
by  the  disease  termed  dry  catarrh  by  Laennec.  It  may,  therefore,  be  denomi- 
nated dry  catarrhal  asthma.  It  is,  perhaps,  the  most  common  form,  of  asthma. 
(See  the  chapter  on  Catarrh  in  the  present  work). 

3.  The  third  variety  of  chronic  catarrhal  asthma  is  that  which  is  combined 
with  the  common  chronic  mucous  catarrh.  It  is  tin;  humeral  asthma  of  the  old 
authors.  In  conformity  with  the  names  given  to  the  preceding  varieties,  it  may 
be  denominated  the  mucous  catarrhal  asthma.  This  form  of  catarrh  is  occa- 
sionally the  consequence  of  those  last  described  :  but  it  is  still  more  frequently 
produced  by  repeated  attacks  of  the  acute  catarrh.  It  is  the  common  chronic 
catarrh,  frequent  in  old  age,  and  by  no  means  uncommon  in  youth.  It  is  often 
the  sequel  of  acute  bronchitis,  and  is,  indeed,  itself  only  a  form  of  the  same 
disease  in  a  chronic  state.  .  .  .  The  preceding  are  the  chief  affections  of  the  bron- 
chial membrane,  of  a  chronic  kind,  with  which  the  asthmatic  paroxysm  is  <  (im- 
plicated. There  are  some  others  of  an  acute  character  yet  to  be  noticed,  and 
which,  when  co-existing  with  the  paroxysms  of  asthma,  entitle  this  to  the 
name  of  the  acute  asthma.  Two  forms  of  this  species  are  met  with  in  practice, 
sometimes  sufficiently  well  marked  to  be  readily  distinguished  ;  but  frequently, 
like  the  other  species  of  asthma,  so  intermingled  as  to  render  the  discrimination 
impracticable. 

B.  1.  The  first  of  these  two  varieties  may  be  termed  the  acute  congestive 
asthma.  Were  it  not  that  we  frequently  see  the  most  extensive  inflammation 
and  consequent  tumefaction  of  the  bronchial  membrane,  without  very  great 
difficulty  of  breathing,  certainly  without  any  0I"  that  extreme  and  peculiar  dys- 
pnoea which  characterizes  the  asthmatic  paroxysms,  we  might  agree  with  Parry 
in  opinion  that  mere  vascular  congestion,  from  sudden  determination  of  blood  to 
this  membrane,  might  account  for  all  the  phenomena  of  asthma.  And  there  can 
be  no  doubt  that,  in  a  certain  class  of  cases,  this  determination  of  blood  is  not 
merely  the  precursor  of  the  spasm,  but  that  it  constitutes  the  greater  part  of  the 
pathological  condition  of  the  affected  parts.  Of  course  there  is  some  modifica- 
tion of  the  nervous  condition  of  the  membrane  previously  to  the  afflux  of  blood 
to  it;  but  it  is  extremely  improbable  that  this  modification  is  of  a  spasmodic 
nature  :  on  the  contrary,  it  can  hardly  be  doubted,  that  this  is  the  morbid  con- 
gestion of  the  blood-vessels  which  irritates  the  muscular  fibres  into  spasmodic 
stricture.  2.  The  last  variety  of  catarrhal  asthma  which  we  shall  notice  may 
be  termed  acute  catarrhal  asthma.  It  only  differs  from  the  last  in  coming  on 
more  slowly,  and  in  being  complicated  with  a  common  catarrhal  affection  of  the 
bronchial  membrane,  instead  of  a  rapid  congestion  of  the  same.  Reasoning  a 
priori,  one  might  expect  cases  of  this  kind  to  be  very  common.  Such,  however, 
is  not  the  fact.  The  disease  which  has  been  termed  the  hay  asthma,  when 
amounting  to  that  degree  of  paroxysmal  violence  deserving  the  name  of  asthma, 
belongs  to  the  form  now  under  consideration ;  although  this  affection  is  much 
more  properly  designated  by  the  name  of  summer  catarrh.'' 

The  following  recapitulation,  extracted  from  the  same  article,  appears  to  me  to 
embrace  the  chief  points  in  the  pathology  of  asthma,  that,  are  well  established. 
[It  will  be  remarked  that  I  take  no  account  of  the  very  important  class  of  cases 
immediately  dependent  on  disease  of  the  heart:  these  will  be  noticed  hereafter 
under  the  name  of  Cardiac  Asthma.] 

1.  In  the  disease  properly  termed  asthma,  there  is  always  present  a  spasmodic 
contraction  of  the  muscles  of  the  bronchi,  and  sometimes  a  similar  state  of  the 
muscles  of  the  trachea,  larynx,  and  external  muscles  of  respiration. 

2.  In  a  small  proportion  of  cases,  the  spasmodic  stricture  may  take  place  (idio- 


SPASMODIC     ASTHMA. 


449 


the  most  rational  indications  of  cure.  I  shall  not  repeat  in  this 
place,  what  was  formerly  stated  respecting  the  treatment  of  ca- 
tarrh :  it  is  with  the  view  of  fulfilling  the  indications  supplied  by 
this,  that  repeated  emetics,  soap,  alkaline  salts,  kermes,  squills, 
ipecacuanha  in  small  doses,  &c,  have  been  had  recourse  to. 
Many  means  may  be  opposed  to  the  disorder  of  the  nervous  func- 
tion in  which  the  asthma  chiefly  consists ;  but  in  this  case,  as  in 
every  nervous  affection,  nothing  is  more  variable  than  the  effect 
of  medicines.  Remedies  which  succeed  best  with  a  great  number 
of  patients,  are  useless  to  many  others ;  and  in  the  same  individ- 
ual, we  find  that  a  medicine  which  at  first  produced  the  best 
effects,  and  with  surprising  quickness,  becomes  entirely  power- 
less after  a  few  days.  For  this  reason  it  is  necessary  to  try  suc- 
cessively several,  and  often  very  different  means.  I  shall  here 
run  over  the  list  of  such  of  these  as  have  proved  most  beneficial. 
I  formerly  took  notice  of  narcotics  as  means  of  lessening  the  need 
of  respiration,  and  of  the  influence  of  sleep  on  dyspnoea.  I  may 
add  to  what  was  there  stated,  that  in  the  case  of  animals  which 
hybernate,  the  quantity  of  air  consumed  in  their  torpid  state,  is 
nearly  a  hundred  times  less  than  in  the  state  of  activity  (being  as 
14  to  1500,)  as  was  proved  by  Mangili  in  the  case  of  the  marmot 
placed  under  a  glass  receiver  in  water.*  This  observation  which 
is  allied  to  those  above  detailed,  accounts  for  the  state  of  tole- 
rable health  and  freedom  from  dyspnoea,  which  many  persons 
enjoy,  whose  respiration,  examined  by  the  stethoscope,  is  three 
or  four  times  less  than  in  the  natural  state.  In  these  subjects, 
all  that  they  require  is  that  they  approximate,  in  some  slight  de- 
gree, the  condition  of  hybernating  animals.     This  theory  appears 

pathically  or  symptomatically)  without  any  previous  disease  of  the  affected 
parts. 

3.  In  the  great  majority  of  cases  the  spasmodic  constriction  is  dependent  on  a 
pre-existing  irritation  of  the  mucous  membrane  of  the  air-passages. 

4.  Phenomena  of  a  very  similar  character  are  sometimes  the  consequence  of  a 
congested  state  of  the  mucous  membrane  of  the  air-passages,  without  any  atten- 
dant spasm. 

5.  The  congested  or  tumefied  state  of  the  mucous  membrane  almost  invariably 
accompanies  the  paroxysms,  whether  this  state  be  a  cause  or  a  consequence  of  the 
spasm. 

6.  The  violence  of  the  paroxysms  is  modified  no  less  by  the  degree  of  the  con- 
gestion than  by  the  degree  of  the  spasm  ;  a  great  congestion  with  slight  spasm 
producing,  probably,  the  same  result  as  a  slight  congestion  with  a  great  degree 
of  spasm. 

7.  In  some  cases,  the  tumefied  or  congested  state  of  the  bronchial  membrane 
passes  off  entirely  with  the  spasm,  without  any  exhalation  from  the  vessels  or 
augmented  secretion  from  .the  mucous  follicles.  More  commonly  there  is  a  si- 
multaneous relaxation  of  the  spasm  of  the  muscular  fibres,  and  an  exhalation 
from  the  mucous  coat.  This  exhalation  most  commonly  puts  an  end  to  the  dis- 
ease for  a  time  ;  not  unfrequcntly,  however,  the  congestive  passes  to  a  more  per- 
manent state  of  inflammatory  irritation,  under  the  form  of  pulmonary  catarrh  or 
bronchitis."     Cyc.  of  Pract.  Med.  Vol.  l.—  Transl. 

*  V.  I.  Mueller,  De  Respir.  fastus  Comm.  physiol.  Lipsice,  1828. 

57 


450  SPASMODIC    ASTHMA. 

to  me  the  more  probable,  from  being  founded  on  the  very  perfect 
analogy  of  several  facts  drawn  from  certain  fortuitous  observa- 
tions, which  seem,  at  first  sight,  very  dissimilar  :  of  this  kind  are 
— the  cessation  of  the  feeling  of  oppression  during  sleep  and  for 
a  few  minutes  after  awaking,  in  most  cases  of  asthma,  and  the 
momentary  relief  of  every  kind  of  dyspnoea  from  the  use  of  nar- 
cotics, and  the  effects  of  quiet  and  darkness.  I  may  add  to  these, 
the  fact,  that  the  greater  number  of  persons  affected  with  an  ex- 
tensive dry  catarrh,  and  who  are  nevertheless  free  from  any  habi- 
tual oppression  on  the  chest,  eat  little  and  sleep  much  ;  and  it 
may  be  remarked  as  not  at  all  surprising  that  there  should  be 
great  difference  as  to  the  necessity  of  respiration  in  different  per- 
sons, any  more  than  in  the  necessity  for  food  or  drink.  We  every 
day  observe,  among  men  living  in  almost  the  same  circumstances, 
some  that  eat  four  times  more  than  others,  and  find  a  still  greater 
disproportion  in  respect  to  drink. 

Narcotics  may  act  not  merely  by  lessening  the  necessity  of 
respiration,  but  also  by  overcoming  the  spasm  of  the  lungs  ;  and 
we  ought,  therefore,  to  have  recourse  to  them  in  every  case  where 
the  exploration  of  the  chest  enables  us  to  detect  either  of  these 
changes  in  the  condition  of  the  nervous  influence.  Experience 
has  long  since  led  medical  men  to  make  much  use  of  medicines 
of  this  class,  in  the  treatment  of  asthma  ;  and  the  following  have 
been  particularly  approved  of:  opium,  belladonna,  stramo- 
nium, phellandrium  aquaticum,  aconitum,  napellus,  colchicum, 
tobacco,  smoked  or  taken  internally,  cicuta,  dulcamara,  hyoscy- 
amus.  All  these  may  be  useful ;  and  we  are  sometimes  under 
the  necessity  of  making  trial  of  them  one  after  another.  The 
best  general  rule  for  their  administration  is,  to  begin  with  a  small 
dose,  to  increase  this  gradually,  and  to  employ  the  plants  in  sub- 
stance, well  preserved  and  recently  powdered.  If  we  employ 
extracts,  they  must  have  been  recently  prepared  and  preserved 
with  great  care.  No  means  would  seem  more  proper  fojr  re- 
lieving the  dyspnoea  which  originates  in  an  increase  of  the 
necessity  of  respiration,  than  the  breathing  of  oxygen.  I  have 
myself  never  made  trial  of  it ;  and  it  is  well  known  to  have  dis- 
appointed those  who  have  employed  it,  notwithstanding  the  eulo- 
gies of  Beddoes  and  Fourcroy.  Besides  narcotics,  several  authors 
have  cried  up  certain  vegetable  substances  which  act  powerfully 
on  the  nervous  system,  and,  among  others,  laurocerasus,  nux 
vomica,  boletus,  suaveolens,  meadow  saffron,  &c.  Substances 
of  another  class,  and  equally  irritating  to  the  stomach  and  nervous 
system,  have  been  tried,  such  as  the  tincture  of  cantharides,  the 
arsenical  solution  and  also  arsenic  in  vapor,  the  sulphate  of  zinc, 
the  muriate  of  barytes.  Of  these  the  only  ones  I  have  made  trial 
of  are,  the  distilled  water  of  the  cherry  laurel  and  the  diluted  prus- 


SPASMODIC    ASTHMA. 


451 


sic  acid.  They  frequently  ease  the  respiration,  but  less  certainly 
than  narcotics.  The  same  is  true  of  the  nitric,  sulphuric,  and 
acetic  aethers. 

After  narcotics,  no  class  of  medicines  has  been  more  recom- 
mended,  or    is,  indeed,   more  frequently  beneficial  in  nervous 
dyspnoea,  than  the  resins  and  fetid  gums,  and  some  other  medi- 
cines  of  analogous  powers.     Musk  and  castor,  more  especially, 
many  times  give  more  speedy  relief;  and  gum  ammoniac,  assa- 
fcetida,  camphor,  singly  or  dissolved  in  the  oil  of  petroleum,  and 
myrrh,   frequently  relieve  the  dyspncea,  and  moreover  favor  ex- 
pectoration when  there  exists  any  catarrhal  complication.     Even 
the  mere  smell  of  these  substances,  and  of  very  odorous  or  fetid 
substances  in  general,  frequently  produces  a  temporary  allevi- 
ation ;  sometimes,  however,  it  is  injurious.     When  the  asthmatic 
paroxysms  have  a  strongly  marked  periodical  character,  cinchona 
frequently  diminishes  their  severity,  and  sometimes  stops  them 
altogether.     An  English  physician,  Dr.  Bree,  has  recently  lauded 
the  subcarbonate  of  iron,  and  coffee,  as  able  not  only  to  dissipate 
an  asthmatic  paroxysm  when  present,  but  to  prevent  its  return. 
The  last  measure,  however,  had  already  been  proposed  by  one  of 
his  countrymen,  Dr.  Percival,  in  his  essays.     I  have  myself  seen 
several  cases  in  which  coffee  was  really  useful.     I  have  also  found 
that  the  subcarbonate  of  iron,  given  in  graduated  doses,  from  a 
scruple    to  a  dram,  was  beneficial  in  retarding    the   accessions 
and  in  lessening  their  violence,  in  persons  of  a  pallid  and  lym- 
phatic constitution,  and  in  habits   relaxed  by  a   long   course  of 
indolent  enjoyment ;  and  it  has  appeared  to  me  equally  beneficial 
whether   the  asthma   depended  chiefly  on  a*  dry  catarrh,  or  was 
almost   purely  nervous,  but  more  frequently  so  in   the  latter  class 
of  cases.      Electricity,  formerly  cried  up  by  Sigaud  de  Lafond, 
(De  PElect.   Med.  p.   250,)  has  been  recently  revived,  particu- 
larly under  the  form  of  galvanism  ;  and  although  it  has  frequently 
succeeded  in  lessening  the  dyspncea,  it  has  occasionally  increased 
it.     I  have  obtained  analogous  effects,  but  less  quickly,  from  the 
application  of  the  magnet. — Emetics  appear  frequently  to  act  not 
merely  as  evacuants,  derivatives,  and   expectorants,  but  also  by 
directly  influencing  the  nervous  system  ;  as  their  employment  is 
often  followed  by  an  intermediate  alleviation  of  the  paroxysm. — 
Whatever  be  the  occasional  causes,  or  the  elements  of  the  asthma, 
we  must  never  omit   blood-letting  whenever  the  lividity  of  the 
countenance,  the  strength   of  the  patient's  constitution,  or   the 
over-action  of  the  heart,  indicate  pulmonary  congestion  ;  but  we 
must  be  careful  not  to  abuse  this  practice,  which  in  general  pro- 
duces only  a  temporary  advantage.     Venesection  is  rarely  useful 
after  the  first  days ;  and  its  too  frequent  repetition,  by  weakening 


452  SPASMODIC    ASTHMA. 

the  patient,  induces  a  risk  if  not  of  life,  at  least  of  greatly  pro- 
longing the  duration  of  the  attack.* 

*  The  treatment  of  asthma,  like  that  of  all  periodic  diseases,  consists  of  two 
parts,  that  proper  in  the  paroxysm,  and  that  in  the  interval.  Laennec  has  not 
made  this  distinction  sufficiently  clear.  It  is  chiefly  in  the  paroxysm  that  blood- 
letting, narcotics,  anti-spasmodics,  emetics,  expectorants,  derivants,  &c.  are  em- 
ployed ;  although  several  of  them  are  also  had  recourse  to  in  the  interval.  I 
must  here  content  myself  with  a  few  remarks  on  some  of  the  more  important  of 
these  means  ;  and,  in  doing  so,  shall  avail  myself  of  the  materials  contained  in  the 
article  Asthma  written  by  me  for  the  "  Cyclopaedia  of  Practical  Medicine."  For 
further  details  I  refer  the  reader  to  that  article. 

1.  Treatment  in  the  -paroxysm. — Blood-letting. — The  extreme  suffering  of  the 
patient  in  the  asthmatic  paroxysm  will  very  naturally  suggest  the  employment 
of  so  powerful  a  remedy  as  blood-letting.  This  is,  accordingly,  one  of  the  meas- 
ures which  the  young  practitioner  is  almost  always  sure  to  have  recourse  to  up- 
on being  first  called  to  a  severe  case.  Experience,  however,  will  inevitably  lead 
to  opinions  less  favorable  to  its  use  than  might  be  anticipated  before  a  sufficient 
trial  of  its  efficacy.  It  is,  no  doubt,  a  very  proper  remedy  in  some  cases;  but 
it  cannot  be  recommended  as  one  that  is  generally  either  useful  or  safe.  It 
may  be  occasionally  necessary  as  an  auxiliary  to  other  means,  or  as  a  mea- 
sure of  precaution  against  the  ill  consequences  likely  to  be  produced  by  the 
paroxysm  on  the  other  parts  ;  but  it  should  never  be  looked  upon  as  a  measure 
to  be  had  recourse  to,  like  many  others,  on  almost  empirical  principles.  It  is  a 
remedy  too  important  to  be  trifled  with.  It  never,  I  believe,  puts  an  end  to  the 
paroxysm,  much  less  does  it  cure  the  disease;  and  its  habitual  employment  in 
an  affection  of  frequent  recurrence  cannot  fail  to  be  highly  injurious.  It  is  in- 
dicated in  the  early  attacks  of  young  and  robust  subjects;  in  cases  of  great 
general  plethora;  in  fits  of  great  violence,  in  which  the  pulmonary  circulation  is 
much  impeded,  and  the  brain  or  other  important  organs  are  likely  to  suffer  in 
consequence.  Cases  of  this  kind  are  denoted  by  the  extreme  violence  of  the 
dyspnoea,  lividity  of  the  face,  stupor,  &c.  Bleeding  with  leeches  is  never 
proper  in  the  asthmatic  paroxysm ;  cupping  maybe  occasionally  useful,  espe- 
cially when  there  exists  much  cerebral  congestion. 

Narcotics,  anti-spasmodics ,  fyc. — Medicines  of  this  class  seem  particularly  in- 
dicated by  the  obviously  spasmodic  character  of  the  paroxysm,  and  by  its  vio- 
lence ;  and  accordingly  they  have  been  very  generally  prescribed  in  it,  in  one 
form  or  other,  from  the  earliest  times.  It  must  be  admitted,  however,  that  the 
success  of  such  remedies  has  been  very  limited,  and  the  practice  but  little  trusted 
to  by  experienced  persons,  whether  practitioners  or  the  subjects  of  asthma. 
In  the  great  majority  of  cases  in  which  opium  and  the  medicines  termed  anti- 
spasmodics have  been  employed,  they  have  failed  to  afford  any  relief;  while  in 
many  they  have  proved  injurious,  either  at  the  time  or  in  their  subsequent 
effects.  A  little  reflection  on  the  pathology  of  the  disease  will  readily  explain 
this  result.  In  most  cases  the  only  portion  of  the  disease  which  such  remedies 
are  calculated  to  relieve,  (the  spasm,)  is  conjoined  with  and  dependent  on  a 
pathological  condition  of  the  bronchial  membrane  over  which  they  have  little 
or  no  control.  This  condition,  if  not  positively  inflammatory,  is  certainly  of 
an  analogous  kind,  and  the  experienced  reader  need  hardly  be  reminded  of  the 
inutility  (to  use  no  stronger  term)  of  anti-spasmodics  in  other  cases  of  spas- 
modic stricture  dependent  on  inflammatory  irritation  of  the  part,  until  this  prima- 
ry irritation  has  been  reduced  by  remedies  of  another  class.  It  is  only  in  cases  of 
pure  nervous  asthma,  or  in  those  symptomatic  dyspnoeas,  stimulating  asthma, 
which  depend  on  organic  disease  of  the  heart,  &c.  that  opium  and  other  narcotics 
and  anti-spasmodics  are  at  all  likely  to  prove  useful ;  and  it  is  only  in  these  cases 
that  they  should  be  prescribed.  In  the  hysteric  asthma  the  good  effect  of  opium 
was  long  ago  recognized  by  Willis,  and  I  have  myself  seen  it  very  successful  in 
the  spurious  forms  just  mentioned.  In  the  true  catarrhal  asthma,  I  have  never 
seen  it  useful,  and  have  often  seen  it  injurious. 

Of  this  class  of  remedies  our  space  will  only  permit  us  to  refer  to  two  or  three 
of  the   principal :  Stramonium   had   formerly  been   strongly  recommended  by 


SPASMODIC    ASTHMA. 


453 


Stoerk  and  others  in  mania,  epilepsy,  &c.  but  experience  of  its  inefficacy  had 
long  occasioned  its  discontinuance  in  such  cases,  when  its  use  was  again  revived 
in   English   practice  in  the  beginning  of  the  present  century,  as  a  remedy  for 
asthma.     It  had  been   previously  employed    in  India  in  the  same  disease  with 
much  reputation,  and  it  speedily  attained  great  fame  upon  its  introduction  by  Dr. 
Sims   into    this    country.     Since   that   time  it   has  been  very  much    used  :  and 
although    its  virtues    are  found    to  be  greatly  less    than    was    at   first  believed, 
they  have  been  satisfactorily  proved  to  be  such  as  to  entitle   it  to  the  first  rank 
among  the    temporary  remedies  of  asthma.     The  mode  cf  its  administration   is 
smoking   it  during  the   paroxysm    in  the  manner  of  tobacco.     Tobacco  has  also 
been  much   employed  by  asthmatics,  either  in  conjunction  with  stramonium,  or 
by  itself.     It  is  considered  in  general  as  beneficial  in  the  paroxysm,  and,  in  the 
estimation  of  some  old  asthmatics,  its  effects  are  not    inferior   to   those  of  the 
former  medicine.      Neither   seems  productive  of  relief  unless  expectoration  is 
excited.     Lobelia  Inflata  has  for  the  last  few  years  more  than  rivalled  stramoni- 
um in  public  estimation  ;  but  I  consider  its  pretensions  to  rest  on  much  slighter 
grounds.     It  has  certainly  been  occasionally  productive  of  great  and  immediate 
relief,  but  has  much  more  frequently  failed  altogether  ;  and  in  cases  where  it 
had  at  first  succeeded,  it  has  lost  its  efficacy  on  repeated  trials.     I  have  found  it 
occasionally  beneficial   in    checking    the   paroxysm   even    in  cases  of  catarrhal 
asthma,  if  given  at  the  very  commencement;  but  have  found  it  more   certainly 
successful,  at  least,  temporarily,  in   spurious  cases  produced  by  hydrothorax  and 
disease  of  the  heart.     Further  trials  are  necessary  to  enable  us  to  speak  confi- 
dently of  its  real  merits.     It  is  given  in  the  form  of  a  saturated  tincture  of  the 
leaves,   in   doses   of  from   half  a  dram  to  a  dram   and   a  half,   or  two  drams. 
Coffee  has  obtained  considerable  reputation  in  asthma.     We  are  informed  by  Sir 
John  Pringle,  that  "  Floyer,  during  the  latter  years  of  his  life,  kept  free  from, 
or  at  least  lived  easy  under  his  asthma,  from  the  use  of  very  strong  coffee."     If 
this  be  true,  the  Knight  of  Litchfield  must  have  found  some  difficulty  in  recon- 
ciling the    utility  of  this  "  hot  drink"  with  his  theories,  or    even  with  his  past 
experience.     But,  be  this  as  it  may,  Sir   John   Pringle  assures  us,  on  his  own 
authority,  that  coffee  is  "  the  best  abater  of  the   paroxysms  of  asthma"  that  he 
has  seen.     He   says   the  coffee  is   to  be   made  very  strong,  ("an  ounce  for  one 
dish,")  and  the  dose  to  be  repeated  every  quarter  or  half  hour.     This   practice 
is  sanctioned  by  Dr.  Bree,  and  has  been  much  used  since  the  publication  of  his 
treatise.     My  own  observation  and  inquiries  lead  me  to  rank  it  with  other  nar- 
cotics and   stimulants,  and,  therefore,  to   place   no   reliance  on  it  as   a  general 
remedy. 

Refrigerants. — Vegetable  acids  and  neutral  salts  of  a  cooling  nature  have 
been  considered  beneficial  by  many,  particularly  nitre  and  vinegar.  Remedies 
of  this  class  have  one  great  advantage  over  many  others  that  have  been  used  in 
asthma,  that  they  are  not  likely  to  prove  injurious,  and  may  prevent  the  admin- 
istration of  such  as  are.  Combined  with  mild  diaphoretics  and  small  doses  of 
ipecacuan,  I  look  upon  them  as  the  safest,  and  perhaps,  on  the  whole,  the  best, 
in  the  most  common  cases,  namely,  the  catarrhal.  Indeed,  it  remains  yet  to  be 
proved  if,  in  the  majority  of  cases  of  asthma,  medicine  possesses  any  resources 
superior  to  those  found  most  useful  in  simple  catarrh. 

Derivants,  in  the  form  of  stimulant  pediluvia,  sinapisms  to  the  feet,  &c.  are 
recommended,  most  particularly  by  foreign  physicians.  I  have  repeatedly  tried 
the  warm  foot-bath.  In  some  cases  it  afforded  relief ;  in  others  it  immediately 
aggravated  the  dyspnoea. 

There  are  two  points  in  the  pathology  of  asthma  which,  in  reference  to  the 
treatment  in  the  paroxysm,  deserve  much  more  attention  than  they  have  hith- 
erto obtained.  These  points  are,  the  very  general  production  of  the  paroxysm 
by  cold,  or  rather,  by  "catching  cold ;"  and  the  identity  of  the  very  earliest 
stage  of  the  disease — that  is,  the  stage  preceding  the  attack  of  actual  dyspnoea — 
with  that  of  common  catarrh.  If  the  invasion  of  this  stage  were  carefully 
watched,  and  means  were  taken  calculated  to  check  its  progress,  it  is  not  to  be 
doubted  that  the  asthmatic  paroxysm  might  be  frequently  prevented.  In  Dr. 
Ryan's  work,  this  precursory  stage  of  asthma  is  noticed,  and  its  frequently  in- 
flammatory character  recognized.  But  it  is  in  the  essay  of  Dr.  Watt  (Cases  of 
Diabetes,  <^c.  p.  248)  that  this  important  part  of  the  pathology  of  asthma  has 
had  justice  done  to  it,  and  the  principles  of  treatment  to  which  it  leads   have 


454  SPASMODIC    ASTHMA. 

been  satisfactorily  explained.  In  several  cases  there  recorded,  the  patients  are 
shown  to  have  been  able  to  recognize  the  approach  of  the  paroxysm  some  con- 
siderable time  before  its  actual  invasion  ;  and  by  adopting  very  simple  measures 
"  to  check  the  cold,"  they  frequently  succeeded  in  averting  the  asthma  for  the 
time.  Those  measures  were  warm  pediluvia,  warm  diluents,  and  diaphoretics 
on  going  to  bed,  and  sometimes  purgatives.  If  these  means  were  followed  by 
evacuations  by  the  skin  and  bowels,  the  fit  was  almost  certainly  prevented.  A 
circumstance  mentioned  by  one  of  Dr.  Watt's  patients  is  well  worthy  of  notice, 
as  strikingly  illustrative  at  once  of  the  pathology  and  proper  treatment  of  such 
cases.  If  the  precursory  symptoms  of  the  attack  had  continued  for  a  number  of 
hours  before  the  patient  had  recourse  to  the  usual  measures,  these  were  found  to 
be  now  worse  than  useless.  "  The  bathing  and  warm  drink,  which,  in  the  ear- 
lier part  of  the  attack,  would  have  prevented  the  fit,  serve  now  to  bring  it  on 
sooner  and  with  more  violence."  I  recommend  this  practice  to  the  particular 
attention. of  the  profession,  convinced  from  my  own  experience,  as  well  as  from 
that  of  the  author  just  named,  and  from  the  soundness  of  the  pathology  on 
which  it  is  based,  that  it  will  be  found  of  the-  most  essential  benefit  in  asthma. 
The  great  uncertainty  and  lamentable  feebleness  of  our  therapeutic  means,  after 
the  disease  is  fully  formed,  enhance  extremely  the  value  of  any  kind  of  treat- 
ment calculated  to  prevent  the  invasion  of  the  paroxysm. 

II.  Treatment  in  the  interval. — It  will  be  obvious  to  any  one  who  considers 
the  pathology  of  asthma,  its  different  forms  and  complications,  its  various  causes, 
and  the  important  modifications  derived  from  difference  of  constitution  in  the 
subjects  of  it,  that  the  treatment  of  this  disease,  in  the  interval,  must  vary 
greatly  in  individual  cases.  Practical  precepts,  which  can  apply  generally, 
must  on  this  account,  be  very  brief.  They  can  only  have  reference  to  the  dis- 
ease in  its  simplest  state,  whether  this  has  been  its  original  character,  or  has 
been  brought  about  by  the  removal  of  its  complications  by  previous  treatment. 
When  called  on  to  treat  any  case,  our  first  object  will  be  to  ascertain  its  pecu- 
liarities ;  and,  having  ascertained  them,  we  must  regulate  our  practice  accord- 
ingly. If  the  paroxysms  of  difficult  breathing  appear  to  be  unconnected  with 
any  very  marked  disorders' of  the  system,  except  such  as  are  considered  to  con- 
stitute an  essential  part  of  the  disease,  we  may  then  proceed  at  once  to  apply 
the  remedies  which  we  consider  best  suited  to  the  cure  of  asthma  in  general. 
If,  on  the  contrary,  we  find,  as  will  generally  be  the  case,  that  the  asthmatic 
affection  is  complicated  with  and  apparently  influenced  by  some  disorder  of  other 
parts,  it  will  be  wrong  to  apply  any  remedies  specially  directed  to  the  cure  of 
the  asthma,  until  these  extraneous  disorders  are  removed,  or  at  least  attempted 
to  be  removed. 

Into  these  complicating  disorders  I  cannot  here  enter  ;  and  I  must  content  my- 
self with  a  mere  reference  to  some  of  the  chief  remedies  applicable  to  the  asth- 
ma itself. 

Cold  bathing. — Of  all  the  means  calculated  to  lessen  the  morbid  sensibility  of 
the  bronchial  membrane  to  the  impression  of  cold — in  other  words,  to  diminish 
the  tendency  in  individuals  to  catch  cold — there  is  none  at  all  comparable  to 
the  application  of  water  to  the  surface  of  the  body,  under  some  form  or  other 
of  the  cold  bath.  In  a  climate  so  cold  and  variable  as  that  of  England,  it  is 
utterly  vain  for  those  who  are  unfortunately  very  liable  to  catarrhal  complaints, 
to  hope,  by  warm  clothing,  comfortable  rooms,  or  any  plan  of  seclusion  from 
the  atmospheric  vicissitudes,  to  escape  them.  The  very  efforts  such  persons 
make  to  avoid  the  unfavorable  influence  of  the  climate  only  render  them  more 
subject  to  it.  Here,  as  in  the  case  of  most  other  evils,  moral  as  well  as  phys- 
ical, the  best  chance  of  success  consists  in  strenuous  resistance.  If  we  do  not 
positively  attack  the  enemy,  we  must  at  least,  if  we  hope  for  safety,  present  a 
bold  front,  and  maintain  a  strong  defensive. 

It  is  only  by  the  return  to  hardier  habits  generally,  and  by  the  practice  of  cold 
bathing,  that  the  persons  whose  cases  we  are  now  considering,  can  hope  to  re- 
establish the  natural  harmony  which  ought  always  to  exist  between  the  animal 
and  the  climate  it  inhabits,  and  which  in  them  has  been  unfortunately  destroyed. 
Cold  bathing  may  be  used  in  various  ways;  in  the  form  of  the  common  plunge 
bath,  the  shower-bath,  or  by  simple  ablution  of  the  exposed  surface.  In  the 
case  of  asthmatics,  the  latter  is  the  mode  generally  preferable  in  the  first  in- 
stance, or  else  the  tepid  shower-bath.     Ablution,  when  proper,  has  a  very  great 


SPASMODIC    ASTHMA. 


455 


advantage  over  all  \he  other  forms  of  bathing,  in  being  attended  with  little 
trouble,  and  being  accessible  to  all.  The  process  consists  in  simply  washing 
with  a  sponge,  towel,  or  piece  of  flannel  dipped  in  water,  the  trunk  of  the  body, 
and  then  drying  it,  using  strong  friction  at  the  same  time.  On  first  commenc- 
ing the  practice,  if  in  winter,  the  chill  must  be  taken  off  the  water.  A  portion 
of  common  salt  must  be  always  dissolved  in  it,  in  the  proportion  of  one  or  two 
ounces  to  the  pint,  or  an  equivalent  amount  of  vinegar  added.  The  time  for 
using  the  water  is  immediately  on  getting  out  of  bed  ;  and  this  is  also  the  best 
time  for  using  the  shower-bath,  if  the  system  is  sufficiently  vigorous  to  bear  the 
shock  without  any  further  preparation. 

Tonics. — The  .special  medicines  which  have  been  most  recommended  and 
used  in  asthma,  belong  almost  exclusively  to  the  class  of  tonics.  But  before 
proceeding  to  notice  these  particularly,  I  must  be  permitted  once  more  to  caution 
the  practitioner  against  their  indiscriminate  use,  without  due  regard  to  the  state 
of  the  system.  Great  discredit  has  been  thrown  upon  many  valuable  medicines, 
and  much  injury  done  to  asthmatic  patients,  by  premature  attempts  to  cure  the 
disease  by  means  of  tonics,  and  other  specific  remedies,  directed  exclusively  to 
act  on  the  nervous  system.  This  is,  indeed,  the  besetting  sin  of  British  prac- 
tice in  chronic  diseases;  and  I  have  good  reason  to  know  that  asthtna  forms  no 
exception  to  a  rule  too  general.  Medicines  of  a  kind  calculated  to  act  with 
great  power  on  the  organ  to  which  they  are  primarily  applied,  are  frequently 
prescribed  without  any  reference'  to  the  existing  condition  of  that  organ.  If 
general  debility  prevails,  and  still  more  surely,  if  the  stomach  refuses  to  perform 
its  functions  with  vigor,  bitters,  bark,  steel,  are  immediately  prescribed,  with 
little  or  no  regard  to  the  state  of  the  stomach,  although  this  may  be  such  as- 
altogether  to  contra-indicate  the  use  of  such  remedies.  While  active  irritation 
or  chronic  inflammation  exists  in  the  intestinal  mucous  membrane,  the  true- 
tonics  are  leeches,  refrigerants,  and  low  diet;  and  it  is  only  after  the  recipient 
has  been  prepared  by  such  means,  that  tonics  can  be  administered  without  injury 
even,  certainly  with  any  prospect  of  benefit. 

Bark,  steel,  and  the  oxyd  of  zinc  are  the  tonics  which  have  been  most  relied 
on  in  the  treatment  of  asthma.  The  well-earned  fame  of  bark  in  the  cure  of 
the  periodical  affections  which  originate  in  malaria,  would  naturally  suggest  its 
employment  in  a  disease  like  that  of  asthma;  and  we  find,  accordingly,  that  it 
has  been  prescribed  and  recommended  by  almost  every  one  who  has  written 
on  this  disease  since  the  introduction  of  cinchona  into  European  practice. 
Floyer  says,  that  nothing  is  more  likely  to  prevent  the  return  of  the  paroxysm 
than  bark  ;  and  that,  even  in  the  cases  of  symptomatic  asthma,  "  though  it  cannot 
prevent  the  fits,  yet  it  greatly  relieves  the  sweats  and  faintness  attending  the 
fits,  and  headachs,  and  makes  the  intervals  of  the  fits  longer."  Bree  recom- 
mends it,  but  less  forcibly.  He  says  it  acts  as  other  tonics,  but  is  inferior  to 
steel.  Ryan  says  that  "  there  are  few  cases  that  will  not  admit  of  its  use,  par- 
ticularly if  the  fits  are  kept  up  by  habit;"  but  he  adds,  that  his  success  with 
this  remedy  "  has  not  generally  answered  his  expectations."  It  does  not  ap- 
pear that  the  observations  made  on  the  use  of  this  remedy  in  the  text,  are  de- 
rived from  personal  experience  of  the  author.  The  fact  appears  to  be,  that  bark 
possesses  no  specific  powers  in  checking  the  return  of  the  common  asthmatic 
paroxysm;  but  that  it  occasionally  acts  beneficially  in  two  classes  of  cases; 
first,  when  the  asthma  is  complicated  with  ague,  as  it  sometimes  is,  and, 
secondly,  when  the  stomach  or  general  system  is  in  a  state  in  which  a  tonic  of 
this  kind  is  beneficial.  If  it  improves  the  general  health,  it  frequently  aids  in 
the  cure  or  relief  of  asthma.  Steel  has  been  even  more  extensively  used  than 
bark,  and,  I  apprehend,  with  more  general  success.  In  the  cases  which  are  at- 
tended by  that  cachectic  slate  of  the  system  indicated  by  more  or  less  of  the 
pale  chlorotic  aspect,  this  remedy  is  often  extremely  beneficial,  by  imparting 
vigor  to  the  stomach  and  system  generally.  Bree  is  a  great  advocate  for  steelr 
which  he  considers  as  preferable  to  all  other  kinds  of  tonics.  Floyer's  expe- 
rience, however,  both  personal  and  professional,  is  rather  against  the  use  of 
steel.  He  says,  "  most  asthmatics  complain  that  steel  heats  them,  stops  their 
stomachs  and  breaths,  and  thickens  the  phlegm,  and  at  last  produces  a  severe 
effervescence  which  gives  the  fit."  He  says,  that'both  himself  and  most  of  his 
patients  were  injured  by  the  use  of  the  chalybeate  mineral  waters,  although 
some  were  better  for  them,  "  the  quantity  of  cool  water  (as  he  simply  observes) 


456  SPASMODIC    ASTHMA. 

doing  more  service  than  the  steel  could  do  injury."  The  fact,  no  doubt,  in  this 
case,  as  in  that  of  bark,  is,  that  success  or  failure  will  depend  upon  the  proper 
application  of  the  remedy.  If  the  general  state  of  the  system  seem  to 
indicate  the  use  of  steel,  and  if  the  state  of  the  stomach  and  bowels  do  not  for- 
bid it,  I  have  no  doubt  that  it  will  often  prove  a  valuable  remedy  in  asthma; 
and  the  class  of  cases  which  are  most  likely  to  be  benefited  by  its  use,  are  either 
those  which  occur  in  what  may  be  called  the  chlorotic  temperament,  or  those 
which  seem  allied  to  neuralgic  affections,  not  dependent  on  malaria,  in  which 
there  can  be  no  doubt  that  steel  is  often  highly  useful.  But  in  any  case,  it  will 
be  the  particular  condition  of  the  digestive  organs  and  the  general  system  that 
will  point  out  the  propriety  of  the  remedy,  and  not  any  supposed  specific  pow- 
ers possessed  by  it  against  the  asthmatic  paroxysm.  If  it  is  contra-indicated  by 
the  presence  of  such  circumstances  as  render  it  useless  or  injurious  in  other 
cases,  the  addition  of  asthma  to  the  group  will  not  in  any  way  remove  this  contra- 
indication. 

Oxyd  of  zinc  has  obtained  celebrity  as  a  remedy  for  asthma,  chiefly  through 
the  publication  of  Dr.  Withers'  Treatise,  in  which  it  is  strongly  recommended, 
as  possessing  extraordinary  powers  in  the  cure  of  this  disease.  The  author 
records  maijy  cases  illustrative  of  its  effects.  In  several  it  certainly  appears  to 
have  been  beneficial ;  but,  like  most  promulgators  of  new  or  favorite  remedies, 
he  has  greatly  exaggerated  its  importance  as  a  general  remedy.  Dr.  Withers 
gave  the  medicine  in  doses,  varying  from  five  to  twenty  grains  twice  or  thrice  a 
day.  This  tonic  may  be  given  in  states  of  the  stomach  when  bark  and  steel  are 
inadmissible;  and  certainly  when  tonics  are  indicated,  it  is  entitled  to  a  trial, 
from  the  ample  evidence  adduced  in  its  favor. 

The  limits  of  this  work  will  not  allow  me  to  notice  other  remedies  or  plans 
of  treatment ;  but  I  cannot  altogether  omit  reference  to  the  very  important 
points — the  effect  of  climate  and  regimen.  Asthma  is  one  of  the  diseases  in 
which  the  effect  of  change  of  climate  or  change  of  air  is  most  conspicuous.  It 
is  the  remark  of  every  writer  on  the  disease  that  certain  patients  have  an 
increase  or  alleviation  of  their  symptoms  upon  changing  their  residence  from 
one  place  to  another.  Sometimes  a  very  slight  change,  as  to  distance,  has  this 
effect ;  and  even  when  little  or  no  difference  in  the  nature  of  the  climate  or 
locality  can  be  discovered.  According  to  my  present  experience  these  remark- 
able results  can  be  explained  on  no  general  principle ;  still,  attention  to  the 
ascertained  influence  of  particular  climates  on  particular  diseases,  and  on  the 
system  in  general,  and  a  close  study  of  the  pathology  of  the  individual  cases  of 
asthma,  will  enable  us  frequently  to  be  of  much  service  to  such  of  our  patients 
as  have  it  in  their  power  to  make  choice  of  their  residence. 

In  selecting  a  climate  for  an  asthmatic  patient,  we  must  be  guided  precisely 
by  the  principles  which  direct  the  application  of  any  other  remedy  or  course  of 
treatment.  A  minute  examination  of  the  individual  case  is  always  essential ; 
and  in  making  this  with  a  view  to  the  application  of  climate,  we  must  endeavor 
to  ascertain,  1st.  the  state  of  the  bronchi ;  2d.  the  state  of  the  general  health,  or 
the  diseases  with  which  the  asthma  may  be  complicated ;  3d.  the  relation,  as  to 
cause  and  effect,  which  these  diseases  bear  to  the  asthma ;  4th.  the  character 
of  the  patient's  general  constitution  or  temperament ;  and,  lastly,  the  ascertained 
effect  of  particular  climates,  localities,  and  seasons,  upon  his  individual  case. 

Although  asthma  is  a  disease  of  every  climate,  and  although  many  patients 
have  their  severest  attacks  in  summer,  there  can  be  no  doubt  that,  in  the  great 
majority  of  cases,  a  mild  and  equable  climate  is  much  more  favorable  to  the 
asthmatic  than  one  that  is  cold  and  variable.  Such  a  climate  proves  beneficial 
in  various  ways,  more  especially  in  the  cases  dependent  on  any  form  of  chronic 
catarrh.  It  tends  directly  to  remove  the  very  basis  of  the  disease — 1st.  by  the 
direct  application  to  the  part,  of  air  of  a  milder  and  more  agreeable  temperature  ; 
2d.  by  rendering  the  attacks  of  acute  catarrh  less  frequent,  and  thereby  afford- 
ing longer  intervals  for  the  restoration  of  the  irritated  membrane;  3d.  by  pro- 
moting the  cure  of  the  accompanying  disorders,  which  frequently  exert  a  most 
unfavorable  influence,  both  on  the  structural  alteration  of  the  membrane,  and 
on  the  spasmodic  affection  of  the  bronchial  muscles ;  and  more  particularly  the 
disorders  of  the  digestive  organs  and  the  skin  ;  4th.  by  enabling  the  patient  to 
improve  the  general  health  and  strength,  and  to  fortify  the  system  against  the 
impression  of  cold   by  constant  exercise  in  the  open  air,  and   by  the  uninter- 


SPASMODIC     ASTHMA. 


457 


rupted  use  of  the  cold  bath  throughout  the  year.  (See  Dr.  Clark's  work  On  the 
Influence  of  Climate  in  Chronic  Diseases.) 

The  diet  in  all  chronic  diseases  is  a  matter  of  great  practical  importance.  It  is 
of  more  especial  importance  in  asthma,  because  disorder  of  the  stomach  is  so  fre- 
quent a  concomitant  and  even  a  cause  of  the  disease.  All  the  good  writers  on 
asthma  are  strong  advocates  for  moderation  in  diet;  and  there  is  no  disease  in 
which  patients  are  more  unanimous  on  the  same  point.  Floyer  is  particularly 
zealous  against  excess  both  in  eating  and  drinking.  "Hunger  and  thirst  (he 
says)  are  the  best  cure  for  the  asthma,  especially  little  and  very  small  drink." 
"  The  less  the  asthmatics  are  nourished,  (he  says  in  another  place,)  the  longer 
are  the  intervals  of  the  fits,  and  the  clearer  is  their  breath."  The  principles 
which  ought  to  regulate  the  diet  are  few  and  simple  ;  but  the  practice  must  be 
modified  by  the  circumstances  of  individual  cases.  Temperance  and  moderation 
are  universally  applicable  and  necessary,  as  is  also  habitual  vigilance  against  be- 
ing seduced  from  the  regularity  of  invalid.habils.  The  particular  system  of  diet 
is  indicated  much  more  by  the  concomitant  affection  than  by  the  asthma  itself. 
If  thedisease  is  unattended  by  any  very  decided  disorder  of  structure  in  the  bron- 
chi, or  elsewhere,  the  diet  may  be  more  generous  and  less  strict  than  under  a 
different  state  of  things.  If  there  is  marked  affection  of  the  bronchi,  with 
little  disorder  of  other  parts,  the  only  circumstance  of  much  importance  to 
be  attended  to  respecting  diet  is,  that  it  does  not  tend,  by  being  over  full,  directly 
to  increase  this  bronchial  affection,  and  to  induce  other  disorders  which  might 
aggravate  the  primary  disease.  But  in  almost  all  cases  of  asthma,  we  have  al- 
ready other  disorders  which  tend  powerfully  to  aggravate  and  keep  up  the  bron- 
chial affection,  and  in  the  alleviation  or  cure  of  which,  diet  is  of  paramount  im- 
portance. In  this  list  we  may  include  dyspepsia,  with  its  numerous  progeny  of 
general  and  local  diseases,  plethora,  gout,  gravel,  diseases  of  the  mucous  mem- 
branes generally,  of  the  liver,  brain,  uterus,  skin,  &c.  <&c.  For  the  dietetic 
management  of  these  diseases  we  must  refer  the  reader  to  the  particular  authors 
who  treat  of  them,  and  to  the  various  treatises  on  regimen  and  diet ;  we  would 
only  here  observe,  that  the  co-existence  of  the  asthmatic  paroxysm  scarcely,  in 
any  degree,  alters  the  diet  proper  in  these  affections. 

LITERATURE  OF  ASTHMA. 

1698.  Floyer  (Sir  J.,  M.D.)  A  Treatise  of  the  Asthma.     Lond.  8vo. 
1703.  Ridley  (H.,  M.D.)  Observationes  de  Asthmate,  &c.     Lond.  8vo. 

1769.  Millar  (J.,  M.D.)  Obs.  on  Asthma  and  Hooping  Cough.     Lond.  8vo. 

1770.  Rush  (Benj.,  M.D.)  A  Diss,  on  the  Spas.  Asthma  of  Children.  Lond.  8vo. 
1773.  Falk  (N.  D.,  M.D.)  A  Treatise  on  Disorders  of  the  Lungs,  &c.  Lond.  8vo. 
1786.  Withers  (Th.,  M.D.)  Treatise  on  the  Asthma.     Lond.  8vo. 

1793.  Ryan  (Mich.,  M.D.)  Obs.  on  the  Hist,  and  Cure  of  Asthma.     Lond.  8vo. 
1795.  Davidson  (W.)  Obs.  on  the  Pulmonary  System,  &c.     Lond.  8vo. 
1797.  Bree  (R.,  M.D.)  Pract.  Obs.  on  Disordered  Respiration.     Lond.  8vo. 
1797.  Lipscomb  (G.)  Obs.  on  the  Hist,  and  Cause  of  Asthma,  in  a  Letter  to  Dr. 

Bree.     Birm.  8vo. 
1804.  Laubender  (B.)  Ueber  die  erkenntniss,  &c.  der  Engbrustigkeit.  Nurn.  8vo. 
1809.  Zallony  (M.)  Traite  de  l'Asthme.     Par.  8vo. 

1811.  Phillips  (SirR.)  Communications  on  Stramonium  in  Asthma.  Lond.  12mo. 

1812.  Lullier-Winslow.     Dict.des  Sc.  M.     (Art.  Asthme.)  t.  ii.     Par. 

1817.  Albers  (J.  C,  M.D.)  Coram,  de  diagnosis  Asthmatis  Millari.     Goett.  12mo. 

1818.  Balfour  (W.,  M.D.)  Illustrations  of  the  Power  of  Emet.  Tartar,  &c.  Ed.  8vo. 
1821.  Ferrus.     Diet,  de  Med.  (Art.  Asthma.)  t.  iii.     Par. 

1821.  Guersent.     Diet,  de  Med.     (Art.  Asthma  Aigu.)  t.  iii.     Par. 

1828.  Suchet  (L.)  Essai  sur  la  Pneumolaryngalgie  ou  Asthme  aigu.     Par.  8vo. 

1829.  Jolly.     Diet,  de  Med.  et  de  Chir.  (Art.  Asthme.)  t.  iii.     Par. 
1829.  Kreysig.     Encycl.  Woerterbuch.     (Art.  Asthma.)  b.  iii.     Berl. 
1833.  Forbes.     Cyclop.  ofPract.  Med.  (Art.  Asthma.)  vol.  i.     Lond. 
1833.  Copland.     Diet,  of  Pract.  Med.  (Art.  Asthma.)     Lond. 

Transl. 


58 


458 


BOOK  THIRD. 


DISEASES  OF  THE  PLEURA. 


CHAPTER  I. 


OF     PLEURISY. 


Pleurisy,  or  inflammation  of  'the  pleura,  derives  its  name  from 
the  pain  of  the  side,  which  is  usually  its  principal  symptom. 
The  word  irX^ptn?  in  the  sense  in  which  it  was  used  by  Hippo- 
crates, properly  speaking,  signifies  every  kind  of  pains  in  the 
side,  particularly  such  as  are  of  considerable  violence,  continued, 
and  accompanied  with  acute  .fever.  This  circumstance,  and  the 
small  progress  made  by  pathological  anatomy  before  the  end  of 
last  century,  gave  occasion  to  many  controversies  respecting  the 
true  characters  and  the  seat  of  pleurisy  ;  some  considering  it  as 
an  inflammation  of  the  pleura,  some  as  an  inflammation'  of  the 
lungs,  others  as  having  its  seat  in  both  these,  or  sometimes  in  one 
and  sometimes  in  the  other ;  while  some  looked  for  its  cause  in 
the  cellular  adhesions  which  so  frequently  unite  the  lungs  to  the 
pleura  of  the  ribs.  At  a  recent  period  we  still  find  these  ques- 
tions discussed  at  length,  and  very  unsatisfactorily  decided,  by 
Morgagni,  who  may  be  considered  as  the  father  of  pathological 
anatomy  ;#  as  well  as  by  Sarcone,  who  was  perhaps  the  most 
remarkable  practitioner  of*  the  last  century .f  More  recently  still, 
one  of  the  oldest  and  most  celebrated  physicians  of  our  time,  con- 
sidered the  subject  under  the  same  point  bf  view.J 

These  questions  are  now  obsolete,  at  least  in  France,  where 
the  term  pleurisy,  ever  since  the  publication  of  M.  Pinel,  has 
been  restricted  to  signify  inflammation  of  the  pleura.  It  is, 
no  doubt,  true  that  pleurisy  and  pneumonia  are  very  frequently 
combined ;  that,  in  cases  where  the  pleura  alone  is  inflamed,  the 
stitch  of  the  side,  which  constitutes  the  principal  character  of 
the  TrXefyins-  of  the  ancients,  and  also  of  many  moderns,  is 
# 

*  Epist.  xx.  38.  Epist.  xxi.  37,  ct  seq. 

t  Istor.  ragion.  de'  mali  in  Napoli,     Napoli,  1765. 

t  Mem.  del'Acad.des  Sciences,  1789.     Observation  qui  prouve,  &C.'par  Portal, 


SIMPLE    ACUTE    PLEURISY.  459 

scarcely  perceptible  or  only  momentarily,  and  in  certain  cases  is 
altogether  wanting ;  and,  on  the  other  hand,  that  in  cases  where 
a  violent  pneumonia  is  complicated*  with  a  very  slight  pleurisy, 
there  is  sometimes  a  most  violent  pain  of  the  side :  at  the  same 
time,  it  is  equally  certain  that  one  of  these  inflammations  may 
exist  without  the  other,  and  that  there  are  even  certain  epidemic 
constitutions  in  which  they  are  commonly  found  distinct.  In 
every  case,  the  nomenclature  adopted  in  this  work,  being  founded 
on  the  difference  of  organs  and  not  of  symptoms,  can  lead  to  no 
confusion :  with  us,  the  term  pleurisy  will  always  signify  in- 
flammation of  the  pleura,  whether  it  is  attended  by  a  stitch  or 
not ;  peripneumony  or  pneumonia  will  always  stand  for  inflam- 
mation of  the  lungs,  even  when  accompanied  by  acute  pain  of  the 
side,  while  pleuro-pneumonia  will  indicate  the  co-existence  of  in- 
flammation in  both  organs.  In  this  chapter  I  shall  consider  the 
pathology  and  treatment  of  pleurisy  under  the  following  heads  : 
— 1.  simple  acute  pleurisy;  2.  acute  hemorrhagic  pleurisy; 
3.  chronic  pleurisy ;  4.  contraction  of  the  chest,  consequent  to 
pleurisy  ;  5.  circumscribed  or  partial  pleurisy  ;  6.  latent  pleurisy  ; 
7.  pleuro-pneumonia  ;  8.  empyema. 

Sect.  I. — Of  simple  Acute  Pleurisy. 

The  anatomical  characters  of  pleurisy  are  drawn  from  the 
state  of  the  pleura,  and  the  alteration  and  augmentation  of  the 
secretion  which  always  accompanies  the  inflammation  of  this,  as 
of  all  serous  membranes. 

The  pleura  in  the  state  of  acute  inflammation  presents  a  punc- 
tuated redness ;  as  if  one  had  traced  with  a  pencil  upon  the 
pleura,  an  infinity  of  small  bloody  spots  of  very  irregular  figure, 
and  very  close  to  one  another.  These  red  points  occupy  the 
whole  thickness  of  the  membrane,  and  leave  small  intermediate 
portions  retaining  the  natural  white  color.  It  cannot  be  doubted 
that  during  life,  the  redness  was  uniform;  and  that  the  punc- 
tuated appearance  as  well  as  the  natural  color  of  the  greater 
part  of  the  membrane,  observed  after  death,  are,  according  to 
the  remark  of  Bichat,  owing  to  that  anatomical  disposition  of 
parts,,  which  frequently  occasions  the  almost  total  disappearance 
of  the  redness  of  erysipelas  after  death.  Besides  this  particular 
redness, — and  even  in  those  instances  where  it  is  very  incon- 
siderable,— we  always  find  the  superficial  blood-vessels  of  the 
pleura  redder,  more  distinct,  and  more  distended  than  in  the 
natural  state.  Many  consider  the  thickening  of  the  pleura  as  a 
very  common  consequence  of  inflammation.  I  must  say,  how- 
ever, that  I  never  clearly  perceived  this ;  and  I  think  there  can 
be  no  doubt  that,  in  the  greater  number  of  cases  wherein  it  had 


460  SIMPLE    ACUTE    PLEURISY. 

been  thought  to  exist,  the  supposed  thickening  has  either  been 
an  extensive  congeries  of  miliary  tubercles  on  the  outer  or  inner 
surface  of  the  pleura, — or*  a  cartilaginous  incrustation  on  the 
parts  covered  by  it,  or,  lastly,  false  membranes,  more  or  less 
dense,  closely  adherent  to  its  internal  surface.  Inflammation  of 
the  pleura  is  always  accompanied  by  an  extravasation  on  its  in- 
ternal surface,  and  which  may  be  considered  as  the  species  of 
suppuration  proper  to  serous  membranes.  This  extravasation 
appears  to  commence  with  the  inflammation  itself.*  It  con- 
sists, usually  at  least,  and  in  my  opinion,  always,  of  two  very 
different  matters :  the  one  of  a  firmer,  semi-concrete  consistence, 
is  usually  termed  false  membrane;  the  other,  very  thin  and 
watery,  is  called  serosity  or  sero-purulent  effusion.  Both  of  these 
exhibit  great  varieties  of  character. 

The  false  membranes  consist  of  a  yellowish-white,  opaque  or 
slightly  semi-transparent  matter,  varying  from  the  consistence  of 
a  thick  pus  to  that  of  boiled  white  of  egg,  or  of  the  buffy  coat 
of  the  blood,  to  which  last  substance,  indeed,  these  adventi- 
tious membranes  bear  a  strong  resemblance  in  all  their  physical 
characters.  This  substance  closely  invests  the  whole  inflamed 
portion  of  the  pleura,  following  it,  when  the  inflammation  is 
general,  through  its  whole  course,  as  well  on  the  lungs  as  on  the 
chest,  and  forming  a  sort  of  complete  inner  lining  of  it.  When 
the  inflammation  is  confined  to  either  the  pleura  pulmonalis,  or 
costalis,  the  inflamed  portion  is  alone  covered  by  the  false  mem- 
brane. In  cases  of  extensive  inflammation,  very  frequently  the 
portions  of  false  membrane  covering  the  lungs  and  costal  pleura, 
are  united  by  bands  of  the  same,  which  extend  from  one  to  the 
other  through  the  serous  fluid  effused  into  the  cavity.  In  such 
cases  the  false  membrane  adheres  but  slightly  to  the  pleura, 
being  readily  separable  by  the  handle  of  the  scalpel.  These 
membranous  exudations  commonly  vary  in  thickness  from  half  a 
line  to  two  lines ;  for  the  most  part  they  are  of  uniform  thick- 
ness, though  occasionally,  they  are  thicker  in  some  points,  espe- 
cially on  the  lower  face  of  the  lung,  and  the  corresponding  parts 
of  the  diaphragm.     In  some  instances,  there  are   partial  eleva- 

*  This  is  doubted  by  other  pathologists.  In  the  article  Pleurisy,  in  the>  Cyclo- 
pedia of  Practical  Medicine,  Dr.  Law  makes  the  following  comment  on  the  opin- 
ion of  Laennec  : — "Although  in  the  larger  cavities,  viz.  the  abdomen,  heart,  and 
chest,  our  examination  may  not  be  capable  of  that  degree  of  precision  which 
would  enable  us  to  pronounce  with  certainty  upon  the  point,  still  there  are  other 
cavities  in  which  the  train  of  morbid  phenomena  takes  place  more  immediately 
under  the  cognizance  of  our  senses,  and  where  we  have  an  opportunity  of  recog- 
nizing a  determinate  interval  between  the  supervention  of  the  inflammation  and 
the  effusion  ;  for  instance,  the  joints  and  the  tunica  vaginalis.  In  iritis  we  have 
occular  demonstration  that  it  is  some  time  after  the  pain  has  announced  the  in- 
flammation, that  the  increased  secretion,  of  the  aqueous  humor  takes  place,  caus- 
ing an  unusual  prominence  of  the  cornea."—  Transl. 


SIMPLE    ACUTE    PLEURISY. 


461 


tions,  or  thickenings,  of  the  membrane  throughout  its  whole 
extent,  in  the  form  of  lines  which  cross  each  other,  so  as  to 
exhibit  a  sort  of  irregular  net-work.  Sometimes  these  linear 
elevations  are  so  close  together,  as  to  give  to  the  membrane  the 
appearance  of  being  studded  or  granulated  with  small  irregular 
tuberosities.  In  both  these  cases,  the  intermediate  points  re- 
maining comparatively  thin  and  diaphanous,  when  contrasted 
with  the  elevated  portions,  give  to  the  membrane  an  appearance 
very  similar  to  the  omentum  when  moderately  loaded  with  fat. 
This  resemblance  is  particularly  striking  after  the  formation  of 
blood-vessels  in  it. 

Occasionally,  and  particularly  when  the  effused  fluid  is  in 
large  quantity,  the  false  membranes  become  separated  from  the 
pleura,  either  wholly  or  in  part,  and  float  loosely  in  the  serum. 
We  sometimes  even  find  pretty  large  masses  of  this  kind,  of  an 
irregular  roundish  shape,  and  looking  as  if  they  had  never  been 
attached  at  all  to  the  pleura.  This,  however,  appears  to  me  in- 
conceivable ;  and  it  seems  probable  that  these  bodies  had  been 
originally  formed  in  the  angular  parts  of  the  cavity  of  the  pleura, 
at  the  origin  of  the  diaphragm,  or  roots  of  the  lungs,  and  had 
acquired  their  globular  forms  after  their  separation. 

The  serous  effusion  which  attends  the  formation  of  false  mem- 
branes is  commonly  of  a  lemon,  or  light  yellow  color,  transpa- 
rent, or  with  its  transparency  only  slightly  disturbed  by  the  inter- 
mixture of  small  fragments  or  filaments,  of  a  concrete  pus,  or 
pseudo-membranous  substance.  In  the  latter  case,  it  very  closely 
resembles  unstrained  whey.  This  resemblance  is  so  great,  that 
some  practitioners  have  really  fancied  that  they  discovered  milk 
itself  in  the  sero-purulent  effusion  of  puerperal  peritonitis;  and 
truly,  such  a  mistake  might  be  pardonable,  did  we  not  find  an 
effusion  exactly  similar  in  the  inflammatory  affections  of  all  se- 
rous membranes,  and  in  men  as  well  as  women.  The  effused 
fluid  is  generally  without  any  smell  in  the  acute  pleurisy.  I  have 
found  it  fetid  only  in  a  single  instance,  in  the  case  of  a  man  who 
died  of  pleuro-pneumonia,  after  imperfect  poisoning  by  opium. 
In  this  case,  the  serosity  and  false  membranes  had  a  sharp  vinous 
odor,  extremely  nauseous.  The  relative  proportions  of  the  ef- 
fused serum  and  albuminous  extravasation,  are  not  at  all  fixed. 
Sometimes  the  serum  is  extremely  abundant,  and  the  membranous 
exudation  very  small,  and  vice  versa.  Generally  speaking,  the 
more  violent  the  inflammation,  the  more  extensive  and  thick  is 
'  the  membranous  exudation.  In  weak  leuco-phlegmatic  subjects, 
on  the  contrary,  we  find  a  great  quantity  of  limpid  serum,  with 
a  small  portion  of  thin  membrane  often  floating  in  it.  In  such 
cases,  the  pleurisy  seems  to  pass  insensibly  into  hydrothorax,  as 
we  shall  see  more  particularly  hereafter.     In  general,  the  more 


\ 


462  SIMPLE    ACUTE    PLEURISY. 

limpid  is  the  serum,  the  less  is  the  quantity  of  albuminous  exuda- 
tion ;  a  circumstance  to  be  expected,  since  the  small  fragments 
that  render  it  turbid  are  derived  from  this.  In  some  rare  in- 
stances, we  find  a  pseudo-membranous  exudation  uniting  the 
contiguous  surfaces  of  the  pleura,  without  any  serous  effusion. 
This  would,  indeed,  be  a  very  common  case,  if  we  took  into  our 
account  those  pleurisies  which  had  made  some  progress  towards 
a  cure,  as  we  shall  find  directly  that  the  absorption  of  the  fluid  is 
the  first  step  in  the  sanative  process.  The  cases,  however,  to 
which  I  here  advert,  are  those  observed  in  persons  dying  of  some 
other  disease,  and  who  were,  at  the  same  time,  affected  with  a 
slight  and  partial  pleurisy.  In  these  cases  we  find  a  white,  al- 
most colorless,  semi-transparent  exudation,  which,  while  recent, 
readily  allows  the  separation  of  the  parts  it  unites,  and  remains 
on  the  surface  of  each,  exactly  like  a  thick  and  moist  paste 
which  had  united  two  leaves  of  paper.* 

In  cases  of  pneumonia,  also,  even  in  those  which  are  slight 
and  partial,  we  sometimes  find  the  pleura  pulmonalis,  in  the 
vicinity  of  the  part  inflamed,  invested  by  a  false  membrane 
of  small  extent,  and  which,  according  as  it  is  more  or  less 
recent,  is  yellow,  opaque,  and  slightly  attached  to  the  neigh- 
boring parts ;  or  firm,  semi-transparent,  reddened  by  the  pres- 
ence of  a  great  number  of  small  vessels,  and  already  divided 
into  membranaceous  layers.  In  some  cases,  we  find  no  serous 
effusion  whatever  after  death  ;  and  I  have  met  with  similar  ex- 
amples of  partial  pleurisy,  in  which  the  stethoscope  afforded  no 
sign  of  liquid  extravasation  ;  although  it  enables  us  to  detect  a 
very  small  quantity,  as  we  shall  see  hereafter.  The  same  remark 
applies  frequently  to  cases  of  phthisis ;  as  it  would  appear  that 
the  close  adhesions,  as  well  cellular  as  cartilaginous,  so  frequently 

*  The  following  particulars  of  the  appearance  of  the  secretion  from  the  pleu- 
ra, in  a  case  of  pleurisy,  are  given  by  Dr.  Law,  (Cyc.  of  Pract.  Med.  vol.  iii.  p. 
388.)  The  difference  presented  by  the  secretion  at  the  different  periods  consti- 
tutes a  very  interesting  feature  in  this  case.  In  a  case  of  acute  pleurisy,  in 
which  the  urgency  of  the  symptoms  required  immediate  paracentesis,  "  the  fluid 
drawn  off  was  of  a  yellowish  color  and  oily  consistence,  very  much  resem- 
bling in  appearance  copal  varnish.  On  remaining  a  short  time  in  the  vessel  in 
which  it  was  drawn,  it  was  converted  into  a  tremulous  jelly,  and  after  some 
hours  resolved  itself  into  two  distinct  parts — a  thickish  crassamentum  floating 
in  a  thin  serum  ;  it,  in  fact,  very  much  resembled  the  blood,  without  its  color- 
ing matter.  The  fluid  having  collected  again,  it  became  necessary,  in  the 
course  of  a  fortnight,  to  repeat  the  operation,  when  w»  found  the  effusion  to 
present  very  different  sensible  properties  from  those  of  the  original  fluid;  it 
was  now  of  a  greenish  color,  and  though  apparently  of  a  homogeneous  consis-  • 
tence,  on  standing  a  short  time  it  separated  into  a  thick  purulent  sediment,  and 
a  thin  greenish  supernatant  liquor.  This  operation  afforded  a  very  temporary 
relief;  the  individual  died  in  four  days,  and  on  examination  we  found  not  less 
than  eight  pints  of  thick  purulent  matter  (such  as  is  met  with  in  a  phlegmonous 
abscess)  in  the  left  side,  and  both  pleura  pulmonalis  and  costalis  densely  coated 
with  lymph." — Transl. 


SIMPLE    ACUTE    PLEURISY. 


463 


found  on  the  upper  lobes  in  this  disease,  are  usually  produced 
in  this  way.  Such  instances  of  partial  pleurisy, — or,  as  we 
might  name  them  in  contradistinction  to  the  others,  dry  pleurisy, 
— are,  for  the  most  part,  mere  complications  of  some  much  more 
serious  disease,  and  are  often  unperceived,  through  their  whole 
course,  both  by  the  physician  and  patient.  A  local  sensation  of 
heat,  or  occasional  slight  and  transient  pricking  pains,  are  the  only 
indications  of  such  an  affection  in  cases  of  consumption. 

Since  the  publication  of  the  first  edition  of  this  work,  too 
much  importance  appears  to  me  to  have  been  given  to  these 
cases  of  dry  pleurisy,  in  some  recent  works,  journals,  and  theses. 
I  am  even  doubtful  whether  any  pleurisies  exist,  in  which  there 
is  simple  secretion  of  a  false  membrane,  without  any  tendency  to 
serous  exhalation  at  the  same  time.  All  the  cases  mentioned 
may  be  reduced  to  two  kinds, — that  in  which  the  effused  serum 
has  been  absorbed  before  death,  and  that  in  which  its  exhalation 
has  been  mechanically  prevented  by  an  indurated  lung.  In 
respect  of  the  first  kind,  we  know  how  rapidly  absorption  takes 
place  in  certain  cases.  M.  Guersent  informs  me,  that  he  has 
found  these  dry  pleurisies  more  frequently  in  children  than  in 
adults  ;  and  we  know  that  absorption  is  much  more  rapid  in  this 
period  of  life.  In  regard  to  the  second  class  of  cases,  I  would 
observe,  that  compression  is  one  of  the  most  powerful  means  for 
promoting  absorption  ;  and  that  in  instances  of  pneumonia  arrived 
at  the  stage  of  hepatization,  in  tuberculated  lungs,  and  in  cases 
of  pretty  close  adhesions  between  the  lungs  and  pleura,  existing 
previously  to  the  pleuritic  affection,  if  serous  exhalation  took 
place,  it  would  probably  be  re-absorbed  immediately.  In  all 
these  circumstances,  at  least,  if  we  find  serum  as  well  as  false 
membranes,  the  former  is  always  in  small  quantity.  Andral  (CI. 
Med.  t.  ii.)  relates  three  cases  which  he  considers  as  examples 
of  dry  pleurisy  ;  but  as  they  were  all  cured,  we  cannot  be  certain 
that  they  were  not  cases  of  simple  pleurodyne.* 

*  M.  Andral  imagines  that  we  might  recognize  the  dry  pleurisy  by  means  of 
the  diminished  intensity  of  the  respiratory  sound,  occasioned  by  the  impediment 
to  the  free  dilatation  of  the  chest,  made  by  the  pain  ;  but  he  seems  to  forget  that 
tli is  impediment  would  not  exist,  if  there  happened  to  be  no  stitch,  and  that  it 
would  be  found  equally  in  the  rheumatic  pleurodyne  ;  and,  moreover,  it  has 
been  proved  by  many  facts,  formerly  stated,  that  the  intensity  of  the  respiratory 
sound  is  far  from  being  always  proportioned  to  the  degree  of  dilatation  of  the 
thorax. — ivthcr. 

It  is  very  clear  that  I  only  mean  those  cases  where  pleurisy  is  attended  with 
pain  :  now  I  maintain  that  in  cases  of  this  sort,  where  the  continuance  of  reso- 
nance in  the  chest  prevents  the  supposition  of  an  effusion,  the  respiratory  sound 
is  much  less  distinct  than  on  the  healthy  side,  which  can  be  explained  only  by 
a  decrease  in  the  distontation  of  the  lung,  occasioned  by  the  pain  felt  by  the 
patient  whenever  he  attempts  to  breathe  somewhat  deeply.  As  to  the  rest,  it 
is  evident  that  this  sign  alone  would  not  suffice  to  distinguish  a  pleurisy  from  a 
•simple  pleurodyne. — Andral. 


464  SIMPLE    ACUTE    PLEURISY. 

I  think  it  necessary  to  notice  in  this  place  a  common  error 
respecting  the  period  at  which  the  pleuritic  effusion  takes  place. 
Many  physicians  imagine  that  it  does  not  occur  till  after  a  certain 
time,  and  even  some  days  ;  and  it  is  this  notion,  no  doubt,  which 
has  given  rise  to  the  common  expression  of  pleurisy  terminated 
by  effusion.  These  opinions  are  incorrect.  I  have  several  times 
observed  all  the  physical  signs  of  effusion, — that  is,  aegophony 
and  absence  of  the  respiration  and  sound  on  percussion, — in  the 
course  of  one  hour  after  the  invasion  of  the  disease,  and  I  have 
seen  the  side  manifestly  dilated  at  the  end  of  three  hours.  On 
the  other  hand,  I  do  not  remember  to  have  met  with  a  single  case 
in  which  the  effusion  was  doubtful  (under  the  stethoscope)  during 
the  first  and  second  day,  and  distinct  in  the  succeeding  days. 
The  utmost  that  we  can  admit  on  this  point  is, — that  the  effusion 
continues  to  increase  for  several  days,  and  that  it  is  only  at  the 
end  of  this  time  that  it  becomes  too  manifest  to  be  overlooked, 
from  the  dilatation  of  the  affected  side,  and*  the  total  absence  of 
sound  on  percussion.  I  am,  however,  convinced  that  the  effusion 
of  serum  is  contemporaneous  with  the  inflammation,  in  all  serous 
membranes. 

It  is  the  character  of  the  false  membranes  produced  in  pleurisy 
to  be  changed  into  cellular  substance,  or  rather  into  a  true  serous 
tissue,  like  that  of  the  pleura  :  and  this  is  the  natural  progess 
of  the  process  when  left  quite  undisturbed.  This  change  is  pro- 
duced in  the  following  manner :  the  serous  effusion  which  ac- 
companied the  membranous  exudation  is  absorbed,  the  com- 
pressed lung  expands,  and  the  false  membranes  investing  it  and 
the  costal  pleura,  become  united  into  one  substance.  By  and 
by,  this  substance  becomes  divided  into  layers,  pretty  thick  and 
opaque,  which  are  separated  by  a  very  small  portion  of  serosity. 
About  this  time  blood-vessels  begin  to  make  their  appearance  in 
it,  the  first  rudiments  of  which  have  the  aspect  of  irregular  lines 
of  blood,  much  larger  than  the  vessels  which  are  to  take  their 
place.  The  blood  seems  as  if  it  had  been  forced  into  the  sub- 
stance of  the  false  membrane  by  a  strong  injection  ;  and  we  find 
the  corresponding  portions  of  the  pleura  redder  than  elsewhere, 
and,  as  it  were,  spotted  with  blood.  After  a  time,  the  pseudo- 
membranous layers  become  thinner  and  less  opaque ;  the  rines 
of  blood  assume  a  cylindrical  shape,  and  ramify  in  the  manner 
of  blood-vessels,  but  still  preserving  their  augmented  diameter. 
On  minutely  examining  these  at  this  stage,  we  find  their  external 
coat  consisting  of  blood  scarcely  yet  concrete,  and  very  red  ; 
within  this  there  is  a  §ort  of  mould,  or  rounded  substance,  whitish 
and  fibrinous,  and  formed  evidently  of  concreted  fibrine,  perfo- 
rated in  its  center,  already  permeable  to  the  blood,  and  evidently 
containing  it.     Eventually  the  layers  of  the  false  membrane  be- 


SIMPLE    ACUTE    PLEURISY. 


465 


come  quite  transparent,  and  nearly  as  thin  as  those  of  the  ordi- 
nary cellular  tissue  ;  and  the  blood-vessels  resemble,  in  every 
respect,  those  which  ramify  on  the  inner  surface  of  the  pleura. 
It  wants,  however,  the  firmness  of  the  natural  cellular  substance, 
being  easily  torn  in  our  attempts  to  examine  it ;  its  vessels  still 
retain  the  large  diameter  indicative  of  their  recent  formation  ; 
and  it  requires  some  considerable  time  for  them  to  attain  the 
perfect  character  of  the  original  tissues  of  the  body.  These 
productions  are  not  homogeneous ;  they  consist  of  many  folds, 
which  are  united  together  by  surfaces  which  are  cellular,  like  the 
outer  surface  of  the  pleura,  and  which  contain  the  vessels  ;  while 
their  exterior  surface  is  smooth,  shining,  and  evidently  exhalent, 
like  the  inner  surface  of  the  pleura  to  which  they  adhere.  I 
have,  sometimes,  though  very  rarely,  met  with  portions  of  fat  in 
the  duplicatures  of  these  bodies.  These  accidental  productions 
have,  for  the  most  part,  a  direction  perpendicular  to  the  surfaces 
whereon  they  originate  ;  that  is  to  say,  the  line  of  their  direction 
from  the  opposite  points  to  which  they  are  attached,  forms,  in 
general,  nearly  a  right  angle  with  the  pleura.  After  having 
attained  this  stage,  whatever  may  be  their  extent,  they  do  not, 
in  general,  affect  the  health ;  the  respiration  even,  except  in  some 
particular  cases,  does  not  suffer  from  their  presence.  They  pos- 
sess, in  faet,  all  the  characters  of  the  natural  serous  tissues,  being 
capable  of  exhalation  and  absorption  like  them,  and  often  con- 
taining, in  cases  of  dropsy,  a  considerable  quantity  of  effused 
serum.  Sometimes  they  even  inflame,  and,  in  this  case,  become 
invested  by  false  membranes,  similar  to  what  they  themselves 
had  originally  been.  This  is,  however,  very  rare ;  and  it  would 
even  seem  that  a  severe  pleurisy,  which  has  terminated  by  nu- 
merous adhesions,  renders  the  part  so  affected  much  less  liable 
to  an  attack  of  the  same  disease,  than  a  sound  part.  I  have  only 
hitherto  met  with  eight  or  ten  instances  of  inflammation  of  these 
adventitious  membranes,  although  nothing  is  more  common  than 
to  find  the  lungs  completely  adherent  to  the  costal  pleura.  It 
is  even  found  that,  in  cases  of  a  second  attack  of  pleurisy  in  a 
person  whose  lungs  adhere  to  the  pleura  from  the  effects  of  the 
first,  the  inflammation,  albuminous  exudation,  and  sero-purulent 
effusion,  do  not  invade  the  adherent  parts :  insomuch*  that  we 
may  lay  it  down  as  a  principle,  that  the  severer  has  been  an 
attack  of  pleurisy,  the  less  likely  is  a  return  of  the  same  disease. 

The  conversion  of  albuminous  exudations  into  cellular  sub- 
stance has  only  been  thoroughly  understood  for  a  short  time, 
although  the  observation  of  the  fact  is  of  very  ancient  date. 
Hippocrates   was  acquainted   with  the   pulmonary  adhesions  ;* 

*  De  Morb.  lib.  ii.  Pulmo  ad  latus  prolapsus ;  also  Lib.  de  Locis 

59 


4li()  PIMPLE    ACUTE    PLEURISY. 

Diemerbroeck  imagined  that  they  must  be  the  product  of  inflam- 
mation and  ulceration  ;*  Boerhaave  considered  them  as  the  con- 
sequence of  pleurisy  .f     Some  observations  of  StollJ  indicate  a 
more    perfect  knowledge  of  the  conversion  of  false  membranes 
into  cellular  substance ;  and  yet,  about  the  same  time,  we  find 
Morgagni,   after   having   collected   and  collated  the   testimonies 
and   opinions  of  authors,    still  uncertain    respecting   them,  and 
inclined  towards  the  ridiculous  notion  of  Vernojus,  who  considered 
them  as  the  effect  of  laughing.^     At  a  still  more  recent  date,  one 
of  the  most  distinguished  professors  of  the  Faculty  of  Medicine 
of  Paris,  imagined   them  to  be  the  result  of  some  sort  of  dis- 
organization   of  the   pleura. ||     The   extensive   investigations   in 
morbid  anatomy  made  over  the  whole  of  Europe,  and  particularly 
in  France,  during  the  last  thirty  years,  leave  now  no  doubt  upon 
this   subject.      One  remarkable   circumstance   relative   to  these 
adhesions  is,  that  although  the  concrete  pus  when  first  thrown 
out  is  identical  on  every  different  organ,  it  nevertheless  invariably 
assumes,  in  its  transformation,  the  texture  of  the  membrane  which 
secretes  it:  this  is  observable,  for  example,   in  the   synovial  cap- 
sules, on  the  surface  of  the  mucous  and  serous  membranes,  and 
in  the  cellular  substance,  respectively. — A  question  may  perhaps 
arise  respecting  the  vitality  of  those  portions  of  coagulable  lymph 
which  we  find  floating  in   the  serum  without  any  attachment  to 
the  membrane  that  secreted  them.     In  those  cases  which  form 
the  connecting  link  between  pleurisy  and  acute  hydrothorax,  I 
have  sometimes  observed  long  filaments  of  this  kind  exhibiting 
marks  of  incipient  transformation  into  serous  tissue,   although 
they  were  floating  loose  in  a  great  quantity  of  serum,  and  ex- 
hibited no  sign  of  having  been  ever  attached  to  the  pleura.     In 
considering  this  subject,  it   is  not  to  be   forgotten  that  fluids  are 
possessed  of  life  as  well  as  solids ;  and  certainly   there  appears 
to  me  a  great  analogy  between  the  formation  of  the  egg  and  the 
conversion  of  the  concrete  pus  into  a  substance  of  the  same  nature 
as  that  which  secretes  it.H 

When  the  pleurisy  is  simple,  we  find  no  sign  whatever  of  in- 
flammation of  the  pulmonary  tissue,  even  in  the  vicinity  of  the 

*  Anat.  lib.  ii.  cap.  13.  t  Prselect  ad  Instit.  sect.  606. 

%  Rat.  Med.  pars  v.  p.  5.  16.  223,  et  seq.  p.  243.  255. 261.  397;  pars  vii.p.210. 

§   Epist.  xvi.  lib.  ii.  sect.  16. 

||   Journ.  Gen.  de  Medecine,  t.  xx.  p.  68. 

If  It  appears  to  me  incorrect  to  give  the  name  of  pus  to  matter  spontaneously 
coagulable.  which  being  deposited  on  the  surface  of  the  serum,  constitutes  the 
false  membranes.  These  two  sorts  of  matter  have  nothing  in  common  except 
the  circumstance  of  proceeding  from  the  blood. 

They  differ  in  many  important  points.  There  is,  for  example,  no  sign  of 
life  in  pus;  the  false  membrane,  on  the  contrary,  is  an  essentially  living  part ; 
it  is  susceptible  of  a  most  evident  ciiculation,  it  exhales  a  serosity,  becomes 
inflamed,  and  may  be  I  he  seat  of  every  sort  of  accidental  production. — Andral. 


ACUTE    HEMORRHAGIC    PLEURISY.  467 

most  inflamed  portions  of  the  pleura ;  only  we  find  the  substance 
of  the  lungs,  in  such  cases,  more  dense  and  less  crepitous,  owing 
to  the  compression  produced  by  the  effused  fluids.  If  the  ex- 
travasation has  been  very  great,  the  lung  becomes  flattened  and 
completely  flaccid ;  it  ceases  to  contain  air,  and  consequently  to 
crepitate ;  its  vessels  are  compressed  and  contain  little  blood ; 
and  the  bronchi  (and  sometimes  even  the  largest  trunks,)  are 
evidently  rendered  smaller.  The  peculiar  texture  of  the  lung, 
however,  is  still  very  perceptible,  there  being  no  trace  of  obstruc- 
tion like  that  produced  in  pneumonia ;  and  if  air  is  blown  into 
the  bronchi,  the  lungs  become  expanded  more  or  less  completely. 
When  the  pleura  is  in  a  healthy  state,  and  free  from  any  ad- 
hesions when  the  effusion  takes  place,  the  fluid  is  spread  over  the 
whole  surface  of  the  lung,  but  is  collected  in  greater  quantity 
on  the  lowermost  parts  and  on  the  side.*  As  the  effusion  in- 
creases, the  lung  is  forced  inwards  and  somewhat  backwards  and 
upwards,  upon  the  mediastinum  and  spine,  where  it  becomes 
•compressed  into  a  smaller  space  than  the  hand  of  the  individual, 
if  the  quantity  of  fluid  is  very  considerable.  Previous  adhesions, 
and  certain  circumstances,  which  I  shall  notice  when  treating  of 
partial  pleurisy,  are  the  only  things  which  alter  the  usual  mode 
of  this  compression.  In  the  former  case,  for  example,  if  adhe- 
sions exist  in  the  upper  part  of  the  lung  only, — a  thing  which 
very  commonly  happens, — the  compression  will  take  place  from 
below  upwards ;  if  they  exist  on  the  lower  part, — which  is 
unusual, — the  result  will  be  the  reverse ;  and  if  they  exist  on 
the  side  only, — which  is  a  still  rarer  case, — the  compression  will 
take  place  from  within  outwards,  and  from  before  backwards. 
Partial  pleurisies,  as  we  shall  find,  present  still  more  remarkable 
deviations  from  the  common  course. 

Sect.  II. — Of  Acute  Hemorrhagic  Pleurisy. 

By  this  name  I  wish  to  designate  the  re-union  of  haemorrhage 
(usually  slight)  with  inflammation  of  the  pleura.  This  case, 
which  is  by  no  means  rare,  differs  from  the  simple  acute  pleurisy, 
not  merely  in  its  pathological  character,  but  even  as  to  its  pro- 
gress and  treatment.  The  effused  serum  is  more  or  less  tinged 
with   blood ;   commonly  the   quantity  of  blood  is   very  small ; 

*  I  cannot  allow  that  whenever  a  liquid  is  effused  in  the  pleura,  it  is  always 
spread  uniformly  over  all  the  surface  of  the  lung.  If  this  were  the  fact,  we 
should  not  hear  in  slight  effusions,  the  respiratory  sound  as  distinctly  under 
the  clavicle  of  the  diseased  side  as  under  that  of  the  other,  and  the  sound 
would  not  continue  uniform  in  these  points.  Further,  in  slight  effusions  we 
should  not  find  on  dissection,  the  liquid  accumulated  merely  behind  the  lung, 
and  between  it  and  the  ribs,  while  the  front  of  this  organ  is  in  immediate  con- 
tart  with  the  walls  of  the  chest. — Andral. 


468  ACUTE    HEMORRHAGIC    PLEURISY. 

sometimes,  besides  that  dissolved  in  the  serum,  there  are  found 
some  small  coagula  of  it.     It  is  very  unusual  for  the  proportion 
of  blood  to  be  so  great  as  to  give  to  the  effusion  the  appearance 
rather  of  a  very  liquid  blood  than  of  an  admixture  of  blood  and 
serum  ;  and  it  is  equally  unusual  to  find  the  coagula  large  or 
numerous.*     In  the  cases  where  this  occurs,  and  which  constitute 
what  the  ancients  called  sanguineous  empyema,  the  hacmorrhagic 
affection    evidently  controls   the  inflammatory ;    the    coagulable 
lymph   is  secreted  in   much   smaller  quantity  than   in  common 
pleurisy,  and  the  false  membranes  are  thin  and  sometimes  cover 
only  a  small  portion  of  the  pleura.f     In  the  more  common  cases, 
in  which   the  serum  is  merely  tinged  with  blood,  the  false  mem- 
branes remain  usually  white,  yellowish,  or  colorless,   on    their 
attached  surface,  over  a  great  part  of  their  extent.      Here  and 
there,  however,  they  are  deeply  charged  with  blood,  as  well  as 
the  corresponding  points  of  the  pleura ;  and  indeed  this  mem- 
brane, throughout,  is  commonly  much  redder    than  in  simple 
pleurisy.     It  is  very  uncommon  for  the  bloody  patches  just  men- 
tioned, to  extend  beyond  the  adherent  surface  of  the  false  mem- 
branes ;  sometimes,  however,  these  are  colored  in  this  manner 
through  their  whole  thickness  but  only  over  a  small  space.     It 
is  much  more  common  to  find  (even  in  cases  where  the  serum  is 
only  slightly  colored)  the  whole  external  or  unattached  surface 
of  the  false  membranes,  of  a  scarlet  or  somewhat   bluish  color : 
and    this  happens,  although  there   may  only  be  comparatively 
few  red  spots  on  the  adherent  surface  of  the  false  membrane,  and 
although  the  interior  of  this  retains  its  natural  whiteness.     It  is 
necessary  to  remark  in  this  place,  in  respect  of  the  deepness  of 
coloring   of  the   patches,   particularly  those   found  on   the  ad- 
herent surface  of  the  membranes,  that  it  is  certainly  heightened 
by  transudation  after  death,  as  will  be   more  particularly  noticed 
when  we  come  to  treat  of  the  diseases  of  the  aorta.     It  appears 
to  me  certain,  from  the  collation  of  the  results  of  many  cases, 

*  A  case  of  this  kind,  however,  is  recorded  by  Andral,  Clin.  Mid.  t.  ii.  obs. 
xv. — Author. 

t  Every  inflammation,  without  doubt,  may  cause  a  sanguine  exhalation,  and 
this  is  only  the  termination  of  another  malady,  of  which  it  is  merely  a  particular 
variety.  But  in  the  serous  membranes,  as  elsewhere,  haemorrhage  may  exist 
independent  of  any  antecedent  inflammation,  and  constitute,  in  a  manner  the 
only  morbid  state.  Thus,  I  have  seen  cases  where  either  in  the  arachnoid,  or 
the  pleura,  or  the  peritoneum,  I  found  the  sole  lesion  to  be  an  effusion  of 
blood;  the  serous  membrane  exhibited  no  alteration.  In  this  class  of  mem- 
branes as  in  the  mucous  membrane,  a  haemorrhage  may  be  all  the  disease.  Be- 
sides these,  there  are  cases  in  which  they  exist  merely  as  one  of  the  elements  of 
a  more  general  affection.  Thus,  I  have  found  these  bloody  effusions  in  the 
pleura  and  the  peritoneum,  in  individuals  who  died  of  severe  small  pox;  most 
often  in  such  cases,  there  had  been  during  life,  other  hemorrhages;  the  pus- 
tules, for  instance,  were  filled  with  blood,  petechias  had  formed  in  the  interval 
spaces;  sanguine  exhalations  had  taken  place  on  the  surface  of  several  of  the 
mucous  membranes,  &.c. — Andral. 


ACUTE    HEMORRHAGIC    PLEURISY. 


469 


that  the  haemorrhagic  pleurisy,  although  frequently  possessing 
this  character  from  the  very  beginning,  in  some  cases  becomes  so 
only  during  the  course  of  the  disease,  and  particularly  at  the 
time  when  the  blood-vessels  begin  to  be  formed  in  the  false  mem- 
branes ;  in  which  case,  the  haemorrhage  is  a  mere  excess  or  aber- 
ration of  the  restorative  operations  of  nature.  These  two  va- 
rieties may  sometimes  be  distinguished  in  practice  :  the  primitive 
haemorrhagic  pleurisy  being  remarkable  from  the  very  beginning 
for  the  severity  of  the  signs  of  effusion  ;  while  the  other  only 
assumes  this  character,  more  or  less  suddenly,  in  the  course  of 
the  disease,  and  after  a  delusive  appearance  of  convalescence. 
Generally  speaking,  in  the  haemorrhagic,  the  effusion  of  fluid  is 
more  abundant  than  in  the  simple  pleurisy.  In  the  former,  also, 
the  tendency  to  absorption  is  much  less,  and  the  cure  when  it 
takes  place,  much  more  protracted.  This  is  the  case  which  most 
commonly  constitutes  the  acute  empyema,  of  which  I  shall  have 
occasion  to  speak  hereafter. 

It  is  chiefly,  and  perhaps  solely,  in  cases  of  haemorrhagic  pleu- 
risy, that  we  meet  with  a  peculiar  transformation  of  the  false 
membranes,  very  different  from  that  described  above.  In  these 
cases,  and  perhaps  also  in  some  others  in  which  the  effusion  has 
been  of  long  continuance,  the  false  membranes  investing  the  lungs 
and  pleura  acquire  a  particular  hardness,  a  sort  of  bluish  semi- 
transparency,  and  an  incipient  fibrous  or  cartilaginous  organi- 
zation.* After  this,  they  are  no  longer  susceptible  of  conversion 
into  the  adventitious  serous  tissue.  When  the  effusion  is  ab- 
sorbed, the  lung,  long  compressed  by  it  and  further  bound  down 
by  the  strong  false  membrane  just  described,  which  completely 
invests  it,  cannot  dilate  itself  promptly  enough  to  keep  pace  with 
the  progress  of  the  absorption  ;  the  ribs,  consequently,  contract, 
and  the  cavity  of  the  chest  is  thus  diminished.  When  the  fluids 
are  completely  absorbed,  the  costal  and  pulmonic  exudations 
come  into  close  contact  and  finally  unite,  so  as  to  form  only  one 
substance.  The  consistence  of  this  becomes  daily  firmer,  and, 
after  a  few  months,  acquires  the  consistence  and  all  the  other 
characters  of  a  fibrous  or  fibro-cartilaginous  membrane.  If  we 
dissect  carefully  this  species  of  membranous  production,  we  find 
that,  although  it  adheres  closely  to  the  pleura  of  the  ribs  and  of 
the  lungs,  it  can  be  detached  from  these  almost  entirely.  If  we 
cut  it  transversely,  we  find  it  composed  of  three  different  layers  ; 
two  exterior,  which  are  opaque,  white,  almost  completely  fibrous, 
sometimes  cartilaginous  and  even  ossified  in  certain  points  ;  and 
one  intermediate,  which  is  semi-transparent,  and  resembling,  in 
every  respect,  the  central  and  most  transparent  portions  of  the 

*  See  a  case  of  this  kind  in  "  Original  Cases,  &c.  by  John  Forbes,  M.D."  p- 
247.— Transl. 


470  ACUTE    HEMORRHAGIC    PLEURISY. 

intervertebral  cartilages.  This  last  layer  is  evidently  the  medium 
of  union  between  the  two  others.  Although  it  be  obviously  a 
posterior  production,  and  can  only  have  taken  place  after  the 
organization  of  the  false  membranes  had  been  far  advanced,  I  do 
not  consider  it  as  strictly  the  product  of  inflammation.  I  would 
rather  consider  it  as  analogous  to  the  gelatinous  and  semi-trans- 
parent exudation,  which  constitutes  the  first  step  in  the  process 
of  re-union  of  the  fractured  ends  of  bone  and  tendon. 

A  remarkable  case  which  occurred  to  myself  corroborates  this 
opinion.  In  examining  the  body  of  a  man  who  died  sometime 
after  being  cured  of  a  chronic  pleurisy,  I  found  the  left  lung 
adhering,  through  its  whole  extent,  by  means  of  a  false  mem- 
brane like  that  just  described.  This  membrane  was  of  a  pretty 
uniform  thickness  (from  three  to  four  lines)  over  its  whole  ex- 
tent, except  opposite  the  fifth  and  sixth  ribs,  where  it  was,  in 
one  place,  eight  lines  thick.  This  increase  was  owing  to  the 
presence  of  a  transparent  and  nearly  colorless  substance,  of 
somewhat  firmer  consistence  than  animal  jelly.  It  became  gra- 
dually much  more  solid  towards  its  exterior,  and  in  the  points 
where  it  was  united  with  the  middle  layer  of  the  accidental  mem- 
brane, it  had  the  look  and  consistence  of  fibro-cartilage.  The 
costal  and  pulmonary  layers,  of  the  accidental  .membrane  were 
quite  fibrous  and  opaque,  and,  in  the  vicinity  of  the  enlarge- 
ment just  described,  were  only  a  line  and  a  half  in  thickness.. 
The  ordinary  thickness  of  these  fibro-cartilaginous  membranes, 
varies  from  two  to  five  lines.  This  gradually  lessens  for  a  time 
after  their  formation ;  it  is  proportioned  to  the  thickness  of  the 
layers  which  have  given  rise  to  it ;  and  is  always  considerably 
less  than  them. 

In  some  cases  of  partial  chronic  pleurisy,  I  am  disposed  to  be- 
lieve that  there  may  be  an  albuminous  extravasation  on  the 
pleura  of  from  one  to  six  inches  square,  without  any  observable 
serous  effusion.  I  have  met  with  exudations  of  this  kind,  which 
were  evidently  very  recent,  as  they  were  still  very  yellow,  and 
hardly  so  consistent  as  indurated  white  of  egg ;  they  united  the 
lungs  and  pleura  together,  and  were  unaccompanied  by  any 
serum,  except  a  few  drops  here  and  there  in  the  substance  of  the 
exudation  itself.  It  is  possible,  however,  that  there  may  have 
been  a  serous  extravasation  in  such  cases,  and  which  had  been 
quickly  absorbed.  It  is  in  this  manner,  perhaps,  that  are  formed 
those  partial  adhesions  of  a  fibro-cartilaginous  nature,  which  do 
not  exhibit  in  a  distinct  manner,  the  three  layers  above  men- 
tioned ;  and  it  is  possibly  in  the  same  way  that  these  cartilagi- 
nous masses  originate,  which  we  sometimes  meet  with  on  the 
summit  of  the  lungs,  in  cases  of  tuberculous  excavations.  I  am, 
however,  of  opinion,  that  the  most  usual  mode  of  formation  of 


ACUTE    HEMORRHAGIC    PLEURISY. 


471 


these  accidental  fibre-cartilaginous  membranes,  is  that  formerly 
mentioned,  particularly  such  as  exhibit  the  three  layers.  These 
appear  to  me  to  be  certainly  the  result  of  a  hsemorrhagic  pleurisy, 
or  irregularity  in  the  natural  process,  whereby  the  blood  vessels 
are  formed  in  the  false  membrane.  It  would  seem  that  at  the 
moment  of  the  exhalation  of  blood  necessary  for  the  formation  of 
the  vessels,  a  certain  quantity  of  fibrine  becomes  intermixed  with 
the  albumen  which  composed  the  false  membrane  in  the  first  in- 
stance, and  thus  disposes  it  to  be  converted  into  fibrous  or  carti- 
laginous tissue.  This  mode  of  formation  is  proved  to  me  by 
many  cases  in  which  I  have  found  them  of  every  degree  of  con- 
sistence. In  every  instance  of  acute  pleurisy  that  has  come 
under  my  notice,  which  has  become  chronic  in  consequence  of 
attendant  haemorrhage,  I  have  always  found  the  attached  portion 
of  the  false  membrane  much  more  consistent  than  the  superficial 
parts,  and  in  a  more  or  less  advanced  stage  of  the  fibrocartila- 
ginous transformation.  Even  when  this  deeper  layer  was  softer, 
it  presented  an  appearance,  in  some  sort,  intermediate  between 
those  of  the  fibrine  of  the  blood,  the  fibrinous  coat  of  the  arteries, 
and  the  common  albuminous  false  membranes.* 

The  possibility  of  this  admixture  of  the  fibrine  of  the  blood, 
or  of  blood  itself,  with  the  pseudo-membranous  albumen,  for 
the  formation  of  the  adventitious  membranes  in  question,  is  sup- 
ported by  several  analogies.  We  observe  not  only  on  the  pleura, 
but  on  other  serous  membranes,  pseudo-membranous  exudations 
strongly  impregnated  with  blood,  or  even  composed  of  layers  of 
half-concrete  albumen  and  coagulated  blood.  The  false  mem- 
branes which  we  sometimes  find  after  chronic  peritonitis,  stained 
of  a  violet,  brown,  or  ochre-yellow  color,  appear  to  me  to  have 
the  same  origin  ;  and  if  we  compare  the  exudation  which  pro- 
duces callus  in  cases  of  fracture,  with  several  analogous  facts  of 
morbid  anatomy,  we  shall  find  it  extremely  probable,  that  the 
exudation  of  fibrine  is  as  necessary  for  the  formation  of  a  bony, 
fibrous,  or  cartilaginous  tissue  of  an  adventitious  kind,  as  the 
exudation  of  albumen  is  necessary  to  the  development  of  the 
serous  tissue  which  forms  the  serous  adhesions  subsequent  to 
pleurisy  or   other  inflammations  of   serous  membranes. — These 

*  I  am  doubtful  of  the  propriety  of  separating  the  form  of  pleurisy  described 
in  this  section,  from  that  described  in  the  preceding;  and  I  am  led  by  my  own 
experience,  to  be  more  than  doubtful  of  the  correctness  of  our  author's  opinion, 
that  it  is  almost  exclusively  in  this  variety  that  the  contraction  of  the  chest  oc- 
curs. Indeed,  I  think  it  will  appear,  from  many  expressions  in  this  and  the  sub- 
sequent sections,  that  M.  Laennec's  own  experience  was  incompatible  with  this 
statement.  I  have  the  satisfaction  to  find  that  M.  Chomel  (Diet,  de  Med.  t.  xvii. 
p.  140)  agrees  with  me  in  this  opinion.  It  is  proved  by  chemical  analysis,  (An- 
dral,  Pricis,  t.  i.  p.  479,)  that  the  false  membranes,  termed  albuminous,  by  La- 
ennec,  contain  fibrine.  The  hemorrhagic  pleurisy  is  briefly  noticed  by  Broussais 
<Phleg.  Chron.  £  I  p.  342-3) .—  Transl. 


472  GANGRENE  OF  THE  PLEURA. 

• 

fibrocartilaginous  membranes  have  been  commonly  described 
under  the  name  of  thickenings  of  the  pleura ;  and  this  is  a  mis- 
take very  likely  to  be  committed  by  those  who  trust  to  their 
mere  appearance,  without  further  examination.  On  dissecting 
them,  however,  we  can  always  separate  them  from  the  pleura, 
which  is  found  of  its  natural  thickness.  We  must  not  confound 
these  membranes  with  the  fibrocartilaginous  incrustations  of  a 
like  nature,  which  are  sometimes  formed  on  the  exterior  or  ad- 
herent surface  of  the  pleura,  and  which  I  have  described  else- 
where.* 

Sect.  III. — Of  Gangrene  of  the  Pleura,  and  of  the  false  Mem- 
branes consequent  to  Pleurisy. — Perforation  of  the  Pleura. 

Gangrene  of  the  pleura  is  a  very  rare  disease ;  it  is  hardly 
ever  general,  or  even  of  any  considerable  extent.  It  is  as  seldom 
a  primary  affection  ;  and  I  have  only  met  with  one  case  where  it 
appeared  to  be  a  termination  of  the  acute  inflammation.  Most 
commonly  it  is  the  consequence  of  the  bursting  of  a  gangrenous 
abscess  of  the  lungs  into  the  pleura,  and  occasionally  it  super- 
venes to  chronic  pleurisy.  The  affected  parts  present  the  ap- 
pearance of  soft  gangrenous  spots,  of  a  brownish  or  blackish 
green,  round  or  irregular,  and  often  not  extending  beyond  the 
pleura.  When  these  gangrenous  patches  have  been  removed  by 
the  softening  down  of  their  substance,  the  borders  of  the  ulcers 
left  behind  remain  blackish  for  a  long  time.  Sometimes  the  parts 
beneath  the  pleura  are  affected  to  a  very  small  depth ;  and  al- 
most always  the  subjacent  cellular  substance  becomes  greenish, 
and  filled  with  serum  to  some  distance  around  the  eschar.  In 
some  instances,  the  intercostal  muscles,  the  neighboring  portions 
of  the  lung,  and  even  the  ribs,  participate  more  or  less  in  the 
disease  ;  and  all  exhale  the  gangrenous  fetor.  A  general  inflam- 
mation of  the  pleura,  and  the  consequent  formation  of  false  mem- 
branes to  a  great  extent,  and  a  copious  effusion,  always  follow 
gangrenous  affections  of  the  pleura,  if  these  are  not  themselves 
the  consequence  of  an  old  pleurisy.  In  every  case,  the  false 
membranes,  whether  old  or  new,  put  on  the  gangrenous  character 
in  a  greater  or  less  degree.  This  is  particularly  observable  in  the 
case  of  a  gangrenous  abscess  bursting  into  the  pleura.  Only 
once  have  I  found  this  state  of  the  pleuritic  membranes,  in  a  case 
in  which  there  were,  at  the  same  time,  some  gangrenous  cavities 
in  the  lung,  half  filled  with  a  greyish  and  horribly  fetid  sanies. 
None  of  these  excavations  communicated  with  the  cavity  of  the 
pleura,  and  yet  this  contained  half  a  pint  of   a  fluid  precisely 

*  Diet,  des  Sc.  Med.     Cartilages  Accidentds. 


GANGRENE    OF    THE    PLEURA. 


473 


similar,  only  somewhat  thinner.  This  flui'd,  which  occupied  the 
lower  part  of  the  right  side,  was  contained  in  a  soft  half-putrid 
membrane  of  a  brownish  grey  color,  and  of  a  strong  gangrenous 
fetor.  It  is  evident  that,  in  this  case,  the  gangrene  of  the  false 
membrane  was  the  effect  of  a  general  condition  of  the  system. 

It  sometimes  happens,  in  chronic  pleurisy,  that  a  gangrenous 
eschar  forms  on  the  pleura,  and  permits  the  effused  fluids  to  es- 
cape through  the  intercostal  muscles,  so  as  to  be  finally  evacu- 
ated, either  naturally  or  artificially,  and  that  the  empyema  is  thus 
cured.  This  species  of  abscess  has  been  long  known ;  and  its 
puncture  constitutes  what  is  commonly  called  empyema  from  ne- 
cessity. It  is,  however,  very  rare :  M.  Recamier  has  only  seen  it 
twice ;  and  I  have  only  met  with  one  case  of  it.  Besides  gan- 
grene of  the  pleura,  nature  has  one  other  way  of  evacuating, 
externally,  the  sero-purulent  effusion  of  the  chest ;  this  is  by  the 
formation  of  an  abscess  between  the  layers  of  the  intercostal 
muscles,  or  between  these  muscles  and  the  skin,  which,  bursting 
both  externally  and  internally,  affords  a  passage  for  the  discharge 
of  the  contained  fluids.  I  have  only  met  with  a  single  case  of 
this  kind.  Andral,  however,  gives  two  cases  of  it  ;*  one  from 
his  own  experience,  the  other  observed  in  England.  A  cure  has, 
perhaps,  more  frequently  followed  the  evacuation  procured  by 
means  of  these  kinds  of  abscesses,  than  that  of  the  artificial  em- 
pyema. This,  however,  is  not  always  complete,  as  it  is  common 
for  the  disease  to  degenerate  into  an  incurable  fistula,  which  is 
frequently  kept  up  by  a  carious  state  of  the  neighboring  ribs. 

It  is  still  more  usual  for  these  collections  of  matter  to  be  evac- 
uated into  the  bronchi.  The  ancient  physicians  considered  the 
rupture  of  an  abscess  of  the  lungs  into  the  pleura,  as  a  common 
cause  of  empyema;  but  they  do  not  appear  to  have  suspected 
the  possibility  of  the  reverse  of  this.  I  believe  Bayle  to  have 
first  clearly  proved  this.  It  scarcely  ever  occurs  but  in  chronic 
pleurisy ;  although  Andral  relates  a  remarkable  case  of  it  in  the 
acute  disease.     (CI.  Med.  t.  ii.  Obs.  xxxvi.)f 

*  Andral  gives  three  cases  of  it,  viz.  one  from  the  Italian  Journals,  besides 
the  two  noticed  in  the  text.  In  cases  of  chronic  pleurisy,  the  escape  of  the 
matter  through  the  walls  of  the  chest  is  by  no  means  very  uncommon.  I  have 
myself  met  with  more  than  one  instance  of  it. —  Transl. 

t  Many  instances  of  this  mode  of  escape  of  the  pus  in  chronic  pleurisy  are 
on  record.  I  have  myself  met  with  a  case  of  the  kind,  and  have  had  several 
undoubted  instancies  related  to  me  by  practitioners.  Broussais  gives  two  cases 
of  gangrenous  perforation  of  the  pleura  pulmonalis  in  chronic  pleurisy;  and 
another  in  which  the  communication  seems  to  have  taken  place  from  simple  ul- 
ceration.    Phleg.  Chron.  t.  ii.  p.  290.  297.  301.—  Transl. 


60 


471  PHYSICAL    SIGNS    OF    PLEURISY. 


Sect.  IV. — Of  the  Signs  and  Symptoms  of  Acute  Pleurisy. 

Physical  signs. — As  soon  as  the  effusion  takes  place,  the 
natural  sound  of  the  chest,  on  percussion,  fails  over  the  whole 
space  occupied  by  the  fluid.  From  this  result  simply,  we  could 
not  indeed  be  certain  whether  the  disease  is  pleurisy  or  pneu- 
monia, although  the  common  symptoms,  general  and  local,  must 
assist  us  in  making  the  distinction.  Under  these  circumstances, 
I  have  seen  physicians  endeavor  to  obtain  a  mark  of  distinction 
between  the  two  diseases,  by  placing  the  patient  in  different  posi- 
tions ;  and  I  have  myself  made  a  like  experiment,  but  without 
any  satisfactory  result.  This  might  be  expected,  since  the  chest 
is  always  full ;  and  fluids  change  place  by  position,  only  in  a  ves- 
sel that  is  more  or  less  empty :  in  the  chest  the  extravasated  fluid 
can  only  change  its  position  by  compressing  the  lung.  It  is  true, 
that  when  the  effusion  is  inconsiderable,  it  tends  to  the  posterior 
or  inferior  parts  of  the  chest,  (when  the  patient  lies  on  the  back,) 
on  account  of  its  being  heavier  than  the  lungs  ;  but  if  it  exists  in 
considerable  quantity,  it  diffuses  itself  over  the  whole  surface  of 
the  lungs,  except  in  the  points  where  old  adhesions  exist.*  To 
these  natural  impediments  to  change  of  position  of  the  extrava- 
sated fluids  may  be  added,  the  increased  fixedness  of  the  lungs 
from  the  compression  of  their  substance  by  the  effusion,  and  from 
the  presence  of  old  adhesions  ;  besides,  even  if  this  motion  of  the 
fluids  were  practicable,  the  frequent  co-existence  of  pneumonia 
would  often  render  the  result  of  percussion  of  no  value,  as  a  mark 
of  discrimination.  The  great  extent  of  surface  over  which  the 
sound  is  wanting,  is,  however,  a  much  more  certain  and  practical 
indication  :  in  the  case  of  pleurisy  it  frequently  happens,  that,  in 
the  course  of  a  few  hours  from  the  attack,  the  dull  sound  exists 
over  the  whole  affected  side,  or,  at  least,  over  its  lower  half, — a 
thing  which  is  never,  or  almost  never,  observed  in  pneumonia. 
But  mediate  auscultation  furnishes  us  with  much  more  certain 
means  of  discriminating  these  two  diseases,  and  enables  us  to  as- 
certain with  precision,  not  merely  the  existence  of  the  effusion, 
but  its  quantity.  The  signs  by  which  the  stethoscope  effects  this 
are,  1st,  the  total  absence,  or  great  diminution,  of  the  respiratory 
sound  ;  and,  2nd,  the  appearance,  disappearance,  and  return  of 
JEgophony. 

f  *  The  experiments  and  observations  of  Piorry,  Reynautl,  and  others,  appear 
to  render  inure  than  doubtful,  the  correctness  of  Laennec's  opinion  respecting 
the  immobility  of  the  fluid  effused  in  pleurisy,  from  change  of  the  position  of 
the  body.  In  fact,  tiie  very  circumstance  of  the  effused  fluid  being  of  greater 
specific  gravity  than  the  air-filled  pulmonary  tissue,  renders  the  change  of  posi- 
tion of  the  fluid  an  inevitable  consequence  of  the  change  of  posture,  in  many 
■cases  at  least. —  Trunsl. 


PHYSICAL    SIGNS    OF    PLEURISY.  47o 

When,  as  is  often  the  case,  the  pleuritic  effusion  is  vrey  copi- 
ous from  its  very  commencement,  the  sound  of  respiration  then  is 
totally  absent  through  the  whole  of  the  side  affected,  except  in  a 
space  of  three  fingers'  breadth  along  the  vertebral  column,  where 
it  is  still  heard,  though  less  strongly  than  on  the  other  side.  This 
complete  disappearance  of  respiration  after  the  existence  of  dis- 
ease for  a  few  hours,  is  quite  pathognomonic  of  pleurisy  with 
copious  effusion,  whether  there  exists  pain  in  the  side  or  not.  In 
pneumonia,  the  disappearance  of  the  respiration  is  gradual,  and 
is  perceived  to  be  unequal  in  different  parts  of  the  chest ;  it  is 
scarcely  ever  quite  wanting  below  the  clavicle ;  and  when  this 
takes  place,  it  is  not  till  after  some  days,  or  even  weeks.  It  is, 
further,  preceded  for  twenty-four  or  thirty-six  hours,  by  the  cre- 
pitus rhonchus,  which  is  quite  characteristic .*  In  pleurisy  with 
copious  effusion,  on  the  contrary,  the  loss  of  the  respiratory  mur- 
mur is  sudden,  equable,  uniform,  and  so  complete,  that  no  effort 
of  inspiration  can  render  it  perceptible.  The  continuance  of  the 
respiration  along  the  spinal  column  is  an  equally  constant  sign. 
This  exists  equally  in  the  chronic  disease,  attended  with  the  most 
copious  effusion;  and  even  in  cases  wherein,  on  examination 
after  death,  the  lungs  are  found  so  much  compressed,  as  to  be 
discovered  with  some  difficulty.  The  thing  is  explained  by  the 
compression  of  the  lungs  backwards  towards  their  roots.  In 
many  cases  the  respiration  still  continues  to  be  perceived  imme- 
diately under  the  clavicle,  when  all  the  other  signs  announce  the 
existence  of  a  large  effusion  ;  a  circumstance  which  is  explained, 
in  such  cases,  by  the  presence  of  old  adhesions  in  that  spot.  But 
when  the  same  thing  is  observed  when  the  extravasation  is  mo- 
derate, we  can  only  infer,  either  that  the  fluid  does  not  reach  so 
high,  or  covers  the  upper  lobe  with  a  very  thin  layer.f  In  these 
cases  of  sudden  and  complete  cessation  of  the  sound  of  respira- 
tion, we  must  not  imagine  that,  although  extensive,  the  extrava- 
sation is  so  abundant  as  it  is  in  many  cases  of  chronic  pleurisy,  in 
which  we  find  the  lungs  completely  flattened  against  the  medias- 

*  It  must  be  added  that  in  pneumonia,  as  soon  as  the  sound  becomes  remark- 
ably dull,  the  bronchial  respiration  almost  always  takes  the  place  of  vesicular 
respiration.  In  pleuritic  effusion,  on  the  contrary,  it  is  intich  more  rare,  being 
heard  only  when  the  effusion  is  slight,  and  even  here  it  is  often  wanting,  only 
the  respiratory  sound  is  weaker  than  on  the  opposite  side.—  Andral. 

t  If  this  be  the  fact,  I  was  right  in  a  preceding  note,  in  not  admitting  the 
pleuritic  effusion  to  be  always  uniformly  spread  over  the  surface  of  the  lungs; 
the  fact  cited  by  Laennec  is  precisely  the  one  which  I  have  made  use  of  to 
combat  his  opinion.  I  do  not  think  even,  that  in  such  cases  there  is  a  thin 
layer  of  liquid  interposed  between  the  top  of  the  lung  and  the  wall  of  the  chest, 
for  this  would  diminish  the  resonance  of  the  thorax,  and  reduce  or  modify  the 
respiratory  sound.  Now  this  certainly  does  not  take  place  in  a  great  number  of 
cases,  in  those  even,  where  no  ancient  adhesion  exists  between  the  lung  and 
the  ribs  :  I  have  assured  myself  of  this  fact  by  autophy  in  several  cases  of  this 
description. — Andral. 


476  PHYSICAL    SIGNS    OF    PLEURISY. 

tinum.      In  the  instances  now  under  notice,  it  would  seem  that 
the  lung  is  suddenly  choked,  as  it  were,  and  ceases  to  admit  the 
air  in  respiration,  although  it  has  hardly  yet  lost  one-fourth  of  its 
volume,  and  is  only  slightly  compressed.     And  it  frequently  hap- 
pens, after  the  lapse  of  a  few  days,  that  the  lung  becoming  habit- 
uated to  the  pressure,  recommences  its  functions :  so  that  we 
again  can  hear  the  sound  of  respiration  in  some  points,  although 
the   effusion  continues   undiminished,  or  even  is  somewhat  in- 
creased.    This  fact  I  have  more  than  once  proved  by  dissection, 
and  by  the  comparison  of  the  signs  of  auscultation  and  mensura- 
tion of  the  chest,  of  which  last  I  shall  presently  have  occasion  to 
speak.     These  copious  and  sudden  effusions  occur  chiefly  in  old 
persons,  or  in  adults  of  weak  and  cachectic  habits,  and  in  the  hse- 
morrhagic  pleurisy.     The  sudden  and  complete  cessation  of  the 
respiration  in  such  cases,  must  therefore  be  considered  as  afford- 
ing a  very  bad  prognostic  ;  as  we  may  be  assured  that  the  con- 
version of  the  false  membranes  into  cellular  substance,  and  the 
absorption  of  the  effusion,  will  take  place  either  not  at  all,  or  im- 
perfectly, and  the  disease  will  soon  pass  into  the  chronic  state. 
In  children  and  persons  of  a  good  constitution,  the  effusion  be- 
comes scarcely  ever  so  suddenly  abundant. 

After  some  hours,  or  even  days,  the  respiration  is  still  percep- 
tible over  the  whole  affected  side  ;  and  even  more  distinctly  than 
we  might  be  led  to  expect  from  the  imperfection  of  the  sound  on 
percussion.     It  is,  however,  much  less  than  on  the  healthy  side  ; 
and  is  without  any  rhonchus,  except  in  the  rare  case  of  a  catar- 
rhal  complication.     If    the   effusion   increases,    the   respiratory 
sound  becomes  less ;  it  then  appears  to  be  heard  more  remotely, 
and   finally  disappears  entirely,    except  at  the  root  of  the  lungs, 
where  it  is  always  more  or  less  perceptible.     The  decrease  of  the 
resonance  from  percussion,  does  not  by  any  means  preserve  this 
regular  progression  ;   the  sound  being  usually  as  dull  at  the  pe- 
riod when  the  respiratory  murmur  is  merely  diminished,  as  when 
it  has  entirely  ceased.     When  the  pleuritic  effusion  is  at  all  con- 
siderable, the  respiration  only  becomes  puerile  on  the  sound  side. 
It  even  sometimes  happens  that  this  puerile  respiration  is  trans- 
mitted through  the  effused  fluid,  and  is  perceived  over  the  whole 
extent  of  the  diseased  side.     To  prevent  this  being  mistaken  for 
respiration  existing  in  the  affected  parts,  we  must  explore  the 
whole  of  these,  and  we  shall  thea  find  that  the  sound  becomes 
louder  the  nearer  we  approach  the  other  side.     Besides,  the  qual- 
ity of  the  sound,  its  distance  and  its  clearness,   indicate  its  real 
site ;  and  this  may  sometimes  be  further  demonstrated  by  a  mo- 
mentary compression  of  the  healthy  side,  which  will  cause  it  to 
cease.     But  exclusively  of  these,   the  other   signs  afforded   by 
segophony,  percussion  and  mensuration >  prevent  any  misconcep- 


PHYSICAL    SIGNS    OF    PLEURISY.  477 

tion  respecting  the  effusion.     This  particular  case  is,  moreover, 
uncommon,  and  only  occurs  in  the  chronic  disease.* 

When  the  effusion  begins  to  diminish,  by  absorption,  this  is 
first  observable  by  the  augmented  intensity  of  the  respiratory 
sound  along  the  side  of  the  spine,  where  it  had  never  quite  dis- 
appeared. Shortly  after,  it  is  perceptible  on  the  anterior-supe- 
rior part  of  the  chest,  and  top  of  the  shoulder ;  and  in  a  few  days 
it  returns  below  the  scapula,  and  at  last  gradually  re-appears, 
successively,  on  the  side,  and  the  lower  part  of  the  chest  before 
and  behind.  Wherever  there  are  adhesions  between  the  lungs 
and  pleura,  of  any  considerable  extent,  the  respiration  continues 
audible  over  them,  in  a  greater  or  less  degree,  throughout  the 
whole  period  of  the  effusion ;  and  the  commencement  of  the  ab- 
sorption is  perceived  by  the  augmented  intensity  of  sound  in 
these  places,  and  in  the  summit  and  anterior  border  of  the  lung 
which  parts  had  been  but  little  affected.  The  return  of  the  res- 
piratory sound  is  much  more  slow  in  pleurisy  than  pneumonia. 
Sometimes,  and  particularly  in  cachectic  subject^  it  is  weeks  and 
even  months,  after  the  re-appearance  of  it  near  the  clavicle,  be- 
fore it  is  perceptible  in  the  inferior  parts  of  the  chest ;  and  often 
for  months  after  the  convalescence  of  a  patient,  it  is  only  one-half 
so  distinct  in  the  affected  side  as  in  the  sound  one.f  This  is  owing, 
I  conceive,  partly  to  the  very  slow  process  by  which  the  false 
membranes  are  converted  into  the  cellular  substance,  and  partly  to 
the  diminution  of  the  inherent  action  of  the  lung,  on  account  of 
the  long  compression  which  it  had  undergone.  The  resonance 
of  the  chest  is  still  longer  in  being  restored,  and,  indeed,  in  many 
cases,  it  never  returns  to  the  natural  condition,  in  consequence  of 
the  contraction  of  the  chest,  which  succeeds  the  absorption  of  the 
fluid.  In  examples  of  this  kind,  percussion  yields  a  completely 
dull  sound  long  after  the  re-appearance  of  the  respiration  under 
the  stethoscope.;); 

The  successive  increase  and  diminution  of  the  quantity  of  the 
extravasation,  are  also  indicated  by  another  sign,  which,  although 
much  less  evident,  less  constant,  and  less  certain  than  the  prece- 
ding, is,  nevertheless,  frequently  of  use :  I  mean  mensuration  of 
the  chest.  If  we  uncover  the  chest  of  a  person  affected  with  pleu- 
risy with  abundant  effusion,  we  shall,  in  most  cases,  easily  per- 
ceive, that  the  affected  side  is  larger  than  the  sound  one.  This 
dilatation  of  the  affected  side  has  been  noticed  by  all  writers  on 

*  M.  Cayol  pointed  out  to  me  a  case  in  which  a  similar  transmission  of  sound 
took  place  through  a  copious  collection  of  air  in  the  chest. — Author. 

t  I  have  even  known  many  individuals  whose  respiration  extended  itself 
less  strongly  on  the  side  where  they  had  pleurisy  many  years  before. Andral. 

X  Sometimes  when  the  pleurisy  has  succeeded  in  a  chronic  catarrh,  the  sound 
on  percussion  returns  before  the  respiratory  sound,  the  air  in  this  case' being  long 
impeded  in  its  passage  by  the  obstruction  of  the  bronchia  by  mucus. Author. 


478  PHYSICAL    SIGNS    OF    PLEURISY. 

empyema  since  the  time  of  Hippocrates ;  but  I  have  ascertained 
that  the  same  thing  takes  place  in  the  effusions  of  a  recent  pleurisy. 
[  have  often  found  it  very  distinct  after  two  days'  illness.  It  is, 
of  course,  much  more  evident  in  lean  than  fat  persons  ;  and  it  is 
very  indistinct  in  women  with  large  mammae.  On  measuring  the 
affected  side  with  a  piece  of  ribbon,  we  find  it  enlarged,  but 
never  so  much  as  it  appears  to  the  eye.  An  increase  of  half  an 
inch  on  the  circumference  is  very  obvious  to  the  sight.  In  pro- 
portion as  the  effusion  diminishes,  the  dilatation  of  the  chest  in- 
sensibly disappears  ;  and  sometimes,  as  we  shall  see  more  partic- 
ularly hereafter,  the  affected  side  becomes  narrower  than  before 
the  disease.* 

To  these  signs  we  must  add  another,  also  formerly  noticed, 
JEgophony ;  a  sign  which  is  quite  pathognomonic  when  it  existt, 
and  which  always  indicates  a  moderate  degree  of  effusion.  I  shall 
not  here  repeat  what  I  stated  formerly,  but  will  merely  remind 
the  reader — 1.  that  segophony  appears  about  the  period  v.  hen 
the  effusion  begins  to  be  somewhat  considerable,  when  the  sound 
on  percussion  becomes  dull,  and  the  respiratory  murmur  fails  in 
the  affected  side  ;  2.  that  it  disappears  when  the  extravasation 
becomes  very  abundant ;  3.  that  it  may  continue  during  several 
months,  when  the  quantity  of  fluid  remains  stationary  ;  4.  that 
after  having  disappeared,  it  re-appears  upon  the  quantity  of  the 
extravasation  being  lessened  ;  5.  that  it  goes  off  entirely  when  the 
fluid  is  altogether  or  nearly  absorbed.  I  would  also  repeat,  that 
the  site  of  this  phenomenon  appears  to  be  the  upper  or  thinnest 
part  of  the  layer  of  effused  fluid  ;  that  where  it  is  present,  we  fre- 
quently observe  also  bronchial  respiration  and  bronchophony  ; 
and,  finally,  that  when  it  is  perceived  over  the  whole  or  greater 
part  of  one  side,  it  indicates  a  moderate  quantity  and  equable 
diffusion  of  fluid  over  the  whole  surface  of  the  lung.  In  this 
case,  we  also  perceive,  almost  every  where,  some  remains  of  the 
respiratory  sound,  the  effusion  being  insufficient  to  compress  the 

*  The  simple  application  of  tlie  hand  upon  the  walls  of  the  chest  may,  like 
mensuration,  afford  some  useful  results  in  pleurisy.  It  was  stated  in  the  First 
Part,  (p.  12,)  that  the  vibrations  communicated  to  the  thoracic  parietes  by  speak- 
ing, are  "  no  longer  observable  when,  through  disease,  the  lungs  have  ceased  to 
be  permeable,  or  are  removed  from  the  walls  of  the  chest  by  an  effused  fluid." 
M.  Reynaud  has  applied  this  observation  to  use,  and  he  states  that,  by  observing 
the  places  where  this  vibration  is  wanting,  we  may  not  merely  recognize  the  side 
on  which  the  effusion  exists,  but  its  extent  and  its  variations  of  level.  The  as- 
certaining whether  the  absence  of  the  vibration  depends  on  pleuritic  effusion  or 
peripneumonic  thickening,  will  be  effected  by  ascertaining  whether  there  exists 
aegophony  or  bronchophony  and  the  crepitous  rhonchus.  It  is  proper  to  remind 
the  reader,  that,  it  is  in  pleurisy  that  the  sound  of  friction,  of  ascent  and  descent, 
was  observed  by  M.  Reynaud,  and  that  this  is  the  sign  of  a  pleurisy  without  effu- 
sion. (See  page  65,  note.)  I  stated  in  a  former  note  how  my  own  observations 
tended  to  confirm  this  diagnostic  sign  ;  and,  a  much  higher  authority,  M.  Andial, 
assures  us  (Clin.  Med.  2nd  edit.  t.  ii.  p.  613J  that  he  has  himself  verified  the 
accuracy  of  all  M.  Reynaud's  observations. — (M.  L.) 


PHYSICAL    SIGNS    OF    PLEURISY. 


479 


lung  sufficiently  to  exclude  the  air  from  it ;  and  should  things 
remain  in  the  same  state  during  the  whole  duration  of  the  dis- 
ease, we  may  be  assured  that  the  lung  is  retained  at  a  small  dis- 
tance from  the  ribs,  by  means  of  adhesions. on  different  points  of 
its  surface. 

iEgophony  is  never  wanting  in  the  beginning  of  pleurisy  in 
cases  wherein  the  pleura  had  been  heretofore  quite  sound  ;  and 
the  only  thing  which  occasionally  prevents  its  being  mfLnifest,  are 
previous  adhesions  over  a  great  portion  of  the  lung.  It  never 
fails  to  re-appear  in  acute  cases,  which  are  rapid  in  their  progress, 
when  the  extravasation  is  sufficiently  diminished  ;  and  it  is  more 
marked  according  as  this  has  been  of  short  duration.  But  in 
chronic  cases,  and  even  in  acute  cases  wherein  the  absorption  is 
slow,  this  renewed  cegophony  (agophonia  redux)  is  much  less 
perceptible,  and  sometimes  is  entirely  wanting  ;  a  circumstance 
easily  explained  by  the  theory  formerly  given  of  this  pheno- 
menon. None  of  the  stethoscopic  signs  are  more  characteristic 
than  this  ;  and,  accordingly,  it  has  been  readily  recognized  by  all 
the  physicians  who  have  sought  to  verify  my  researches.  Andral 
has  taken  notice  of  aegophony  in  most  of  his  cases  of  pleurisy, 
although  many  of  these  were  recorded  at  a  period  when  he  evi- 
dently had  little*  acquaintance  with,  or  experience  of,  ausculta- 
tion ;*  he  has  also  several  times  noted  renewed  aegophony  upon 
the  decrease  of  the  effusion.f  To  the  foregoing  physical  signs 
we  have  to  add — the  depression  of  the  liver,  in  cases  where  the 
effusion  is  extremely  copious.  Stoll  even  observed  a  similar  de- 
pression of  the  spleen,  in  one  case,  from  a  collection  of  fluid  in  the 
left  side  ;.  but  this  viscus  must  be  morbidly  large  before  it  can 
be  felt  by  the  hand,  even  in  such  a  case.J 

*  Clin.  Med.  t.  ii.  obs.  4,  5.  7,  8,  9.  12.  15,  16.  21.  26.  30.  32,  33. 

t  Ibid.  obs.  5.  7.  15,  16. 

t  To  a  complete  master  of  auscultation  and  pathology,  like  our  author,  I  am 
willing  to  concede  the  ability  to  distinguish  pleurisy  from  pneumonia  in  even- 
period  of  the  disease,  and  even  to  recognize  their  respective  presence  when  co- 
existing in  the  same  individual.  I  am,  however,  ready  to  confess  that  I  have 
not  always  been  able  to  make  this  distinction  ;  and  I  find  that  I  am  not  singular. 
in  this  respect,  among  the  followers  of  Laennec.  See  Andral's  Clin.  Med  t.  ii. 
p.  574  ;  and  a  paper  just  published  by  Dr.  Stack  in  vol.  iv.  of  the  Dublin  Hosp. 
Reports,  p.  90.  In  making  this  admission,  I  feel  it  but  just  to  add  my  convic- 
tion, that  the  instances  are  extremely  rare  in  which  a  careful  attention  to  the 
history  of  the  case,  and  to  the  general  and  local  symptoms,  together  with  the 
practice  of  auscultation  and  percussion,  will  not  enable  any  one  to  make  the  dis- 
tinction in  question.  And  here  I  would  again  impress  upon  the  student  the  ne- 
cessity, in  all  cases,  of  attending  to  the  common  symptoms  as  well  as  to  the 
physical  signs;  and,  still  more,  the  necessity  of  acquiring  a  thorough  knowl- 
edge of  the  natural  history  and  pathology  of  every  individual  disease,  before  any 
attempt  is  made  to  recognize  it  in  the  living  body  by  means  of  auscultation. 
With  all  its  wonderful  power  and  precision  even  the  stethoscope  opens  no  royal 
road  to  the  knowledge  of  discuses  :  without  attention  to  the  common  symptoms, 
mistakes  will  frequently  occur ;  without  an  acquaintance  with  pathology,  the 
grossest  errors  arc  inevitable. —  Transl. 


480  SYMPTOMS    OF    PLEURISY. 

Double  Pleurisy. — It  occasionally  happens  that  the  pleura  is 
inflamed  on  both  sides  of  the  chest  at  the  same  time.  This,  how- 
ever, is  a  rare  event,  if  we  except  those  slight  double  pleurisies 
which  occur  a  very  fe.w  hours  before  death,  in  most  acute  and 
chronic  diseases  during  the  prevalence  of  an  inflammatory  con- 
stitution. In  cases  of  this  kind,  it  is  by  no  means  unusual  to 
meet  with  slight  pleuritic  effusion  on  both  sides,  together  with 
some  thin  rfalse  membranes,  soft  and  evidently  recent.  Neither 
is  it  very  rare  to  find,  in  the  case  of  a  severe  pleurisy  or  pleuro- 
pneumonia, the  sound  side  become  affected  during  the  last  hours 
of  life.  It  is,  however,  extremely  rare  to  see  the  pleura  of  both 
sides  simultaneously  attacked  with  violent  inflammation,  accom- 
panied by  numerous  false  membranes  and  an  abundant  effusion ; 
and  when  a  case  of  this  kind  occurs,  it  is  almost  always  speedily 
fatal.  Indeed  the  same  result  very  generally  ensues  when  there 
is  copious  effusion  on  one  side,  and  slight  effusion  on  the  other, 
or  even  when  there  is  a  middling  effusion  on  both.  If  we  occa- 
sionally see  double  pleurisies  last  some  time,  or  even  become 
chronic,  we  may  be  certain  they  are  partial  and  of  small  extent, 
on  one  side  at  least ;  and  even  that  the  affection  on  one  of  the 
sides,  most  commonly  supervenes  only  a  very  short  time  before 
death.  Cases  of  this  kind  are  recognized  by  tUe  same  signs  as 
the  single  pleurisy  ;  only  that,  in  them,  percussion  and  the  in- 
spection of  the  chest  scarcely  ever  afford  any  indication.  /Ego- 
phony,  however,  and  the  exploration  of  the  respiration,  enable  us 
readily  to  recognize  them,  except  when  they  are  merely  precur- 
sors of  death  ;  in  which  case  their  investigation  is  equally  unin- 
teresting as  useless. 

Local  symptoms. — The  local  symptoms  of  pleurisy  are,  the 
stitch,  dyspnoea,  cough  and  recumbency  on  the  affected  side. 
These  symptoms  are  more  or  less  variable.  The  stitch  is  the 
most  constant,  but  it  is  occasionally  wanting  in  the  most  acute 
cases  ;  it  may  exist  in  any  part  of  the  chest,  but  is  most  common 
below  the  nipple,  or  on  the  side,  at  the  same  height.  Sometimes 
it  shifts  its  place ;  and  it  is  even  by  no  means  unusual  to  find  it 
passing  to  the  other  side,  without  any  transference  of  the  inflam- 
mation :  occasionally  even,  from  the  beginning  of  the  disease,  we 
have  the  stitch  on  the  right  side  and  the  pleurisy  on  the  left. 
This  pain  is  increased  by  inspiration,  (which  action  it  therefore 
impedes,)  and  is  extremely  aggravated  by  cough.  Pressure,  even 
in  the  intercostal  spaces,  seldom  excites  it ;  and  never  except 
there  exists  a  rheumatic  affection  of  the  muscles.* — The  dyspnoea 

*  My  own  experience  leads  me  to  consider  a  tenderness  of  the  intercostal 
spaces  on  pressure  as  far  from  unusual  in  acute  pleurisy ;  and  as  extremely  com- 
mon in  chronic  pleurisy.  I  am  supported  in  this. opinion  by  Andral  (CI.  Med. 
t.  ii.  p.  555),  by  Chomel  (Diet,  de  Med.  t.  xvii.  p.  159)  and  also  by  Broussais 
(Phleg.  Chron.  t.  i.)— Transl. 


SYMPTOMS    OF    PLEURISY. 


481 


is  very  variable  as  to  intensity.  In  some  cases  the  patients  are 
unconscious  of  its  existence,  although  it  is  perceptible  to  the  bft 
slanders  ;  and  sometimes  it  is  equally  unobserved  by  both ;  in 
other  cases  it  is  extremely  urgent,  and  speedily  reaches  the  de- 
gree of  impending  suffocation.  When  the  dyspnoea  is  not  severe, 
it  appears  to  be  rather  occasioned  by  the  pain  of  the  side,  which 
moderates  the  inspiration,  than  by  the  compression  of  the  lung 
by  the  effused  fluid  ;  since  we  find  that  it  commonly  ceases,  after 
a  few  days,  with  the  pain  and  other  symptoms  of  acute  inflam- 
mation, although  at  this  time  the  effusion  is  more  copious  than 
before.  No  doubt  the  influence  of  habit  and  the  development 
ot  puerile  respiration  in  the  sound  side,  contribute  considerably  to 
the  diminution  of  dyspnoea  in  this  case.  The  following  circum- 
stances have  most  effect  in  producing  extreme  dyspnoea:  1.  a 
dry  catarrh  anterior  to  the  pleurisy,  which  prevents  the  respira- 
tion from  becoming  puerile  in  the  sound  side ;  2.  a  spasmodic 
asthma,  producing  the  like  effect ;  3.  an  extremely  copious  ex- 
travasation occurring  early,  increasing  rapidly,  and  giving  rise, 
in  the  course  of  a  few  days,  to  anasarca  of  the  affected  side  and 
even  of  the  whole  body.*  This  last-mentioned  case  is  rare  in  sim- 
ple acute  pleurisy ;  it  is  more  common  in  the  hsemorrhagic  va- 
riety, and  in  those  cases  which  assume  a  chronic  tendency  from 
their  origin  ;  it  constitutes  the  acute  empyema. — The  cough  is 
usually  infrequent,  dry  and  moderate  ;  sometimes  it  is  altogether 
wanting.  If  expectoration  exists,  it  is  scanty,  pituitous,  or  con- 
sisting of  a  colorless  mucus,  at  times  intermixed  with  some 
streaks  of  blood ;  it  is  only  mucous  and  plentiful,  when  the  pleu- 
risy is  complicated  with  pulmonary  catarrh. — The  patient  gene- 
rally lies  on  the  affected  side,  or  on  the  back ;  and  cannot  turn 
on  the  sound  side  without  experiencing  a  great  increase  of  dysp- 
noea. The  contrary,  however,  is  by  no  means  uncommon ;  as 
many  patients  can  only  lie  on  the  side  not  affected.  But  all  the 
other  local  symptoms,  as  well  as  this,  may  be  wanting;  and  this 
is  the  case  to  which  we  give  the  name  of  the  latent  acute 
pleurisy.  * 

General  symptoms. — A  high  fever  attends  pleurisy  from  its 
invasion.  Most  commonly,  however,  this  only  lasts  a  few  days, 
particularly  if  the  disease  is  treated  by  prompt  bleedings.  The 
fever  ceases  along  with  the  stitch,  and  the  patient,  finding  his 

*  It  is  very  seldom  that  an  effusion  in  the  pleura,  how  plentiful  soever,  and 
rapid  as  it  may  be  in  formation,  causes  anasarca  either  on  that  side  or  over  the 
whole  body.  There  was  a  time  when  a  slight  swelling  of  the  hands  or  feet, 
accompanied  with  a  difficulty  of  breathing,  were  always  considered  as  symp- 
toms of  the  commencement  of  dropsy  in  the  chest,  and  all  supervening  accidents 
were  referred  to  this  disorder.  We  know  at  the  present  day,  that  dropsy  and 
anasarca  are  caused  by  other  lesions,  most  commonly  by  an  affection  of  the 
heart. — Andral. 

61 


482  SYMPTOMS  OF  PLEURISY. 

appetite  and  strength  return,  fancies  himself  cured,  although 
there  still  exists  an  abundant  extravasation  in  the  chest,  which 
cannot  be  got  rid  of  for  a  long  period,  even  should  nothing  inter- 
fere to  check  the  process  of  absorption.  And  the  physician  who 
does  not  explore  the  chest,  must  fall  into  the  same  mistake  as  his 
patient.  I  have  known  cases  in  whieh  the  thoracic  resonance  and 
respiratory  sound  have  not  completely  returned  before  the  expi- 
ration of  six  months,  although  the  patients,  judging  from  the 
continuance  of  the  pain  and  fever,  asserted  that  they  had  only 
been  ill,  in  all,  four  or  five  days.  It  is  very  rare,  even  in  the 
mildest  cases  of  acute  pleurisy,  and  in  which  the  inflammation  is 
most  speedily  checked,  for  the  effusion,  if  at  all  considerable,  to 
be  completely  absorbed,  and  the  false  membranes  converted  into 
cellular  substance,  in  less  than  a  month  ;  most  commonly  this  is 
not  effected  in  less  than  two  or  three.  When  from  any  cause  the 
absorption  is  checked,  the  pulse  becomes  again  frequent,  a  slight 
fever  arises,  and  the  disease  becomes  chronic,  or,  at  least,  the 
absorption  of  the  extravasated  fluid  is  retarded  for  several  weeks 
or  even  months.  I  have  known  cases  of  pleurisy,  very  acute  at 
their  onset,  in  which  the  chest  was  not  freed  from  fluid  before  the 
end  of  two  years.  Generally,  indeed,  even  the  true  and  simple 
pleurisy  does  not  preserve  the  character  of  an  acute  disease,  be- 
yond the  first  days,  and  rarely  does  it  prove  fatal  within  this 
period.  This  disease  has  an  essential  tendency  to  become  pro- 
longed ;  and,  indeed,  the  state  of  resolution  of  the  most  acute 
pleurisy  has  all  the  characters  of  a  chronic  affection.  After  all, 
the  extreme  frequency  of  pulmonary  adhesions  proves,  that  the 
greater  number  of  pleurisies  are  sooner  or  later  cured.  The 
double  pleurisy  is  commonly  latent,  not  only  on  account  of  the 
frequent  absence  or  dullness  of  the  pain,  but  because  it  occurs 
only  as  an  intercurrent  affection  of  some  other  dangerous  disease. 

The  occasional  causes  of  pleurisy  are  those  of  inflammatory 
diseases  in  general.  The  inclemency  of  winter,  and  the  long  con- 
tinued impression  of  cold  after  violent  exercise,  are  the  most  com- 
mon. The  nfetastasis  of  gout,  rheumatism,  or  cutaneous  erup- 
tions, the  suppression  of  an  habitual  discharge,  and  causes  of  a 
purely  mechanical  nature,  such  as  a  blow  on  the  chest  or  fracture 
of  the  ribs,  have  sometimes  produced  the  disease.  It  has  even 
been  asserted  by  some  creditable  observers,  to  be  contagious,  in 
certain  epidemics  ;*  and  the  same  may  be  said  of  many  inflam- 
matory and  other  diseases. 

Among  predisposing  causes,  the  most  evident  are,  a  slender 
frame,  narrowness  of  the  chest,  the  immoderate  use  of  spirits, 
and  most  of  all,  tubercles  in  the  lungs.     These  last,  even  previ- 

*   Valleriola,  lib.  vi.  obs.  ii. ;  Maret,  Nouv.  Mem.  de  l'Acad.  de  Dijon,  1784. 


CHRONIC    PLEURISY. 


483 


ously  to  their  becoming  soft,  seem  to  be  the  cause  of  those  suc- 
cessive attacks  of  pleurisy  in  the  same  person,  which  we  some- 
times meet  with,  and  which  have  a  great  tendency  to  become 
chronic. — In  conclusion,  I  would  remark  of  pleurisy,  as  of  pneu- 
monia, that  the  occasional  and  predisposing  causes  are  frequently 
hidden  from  us,  or  at  least  seem  insufficient  to  account  for  the  at- 
tack. Thus,  for  instance,  although  we  frequently  find  in  youth 
and  middle  life,  that  plethora,  violent  exercise,  a  debauch  or  cold, 
frequently  occasion  pleuiisy  ;  we  know  that  it  is  still  more  fre- 
quent among  old  persons,  in  subjects  of  delicate  constitution,  and 
valetudinarians  who  take  great  care  of  their  health.  The  most 
severe  cases  occur  in  the  weakest  subjects,  in  persons  of  a  ca- 
chectic habit,  or  in  such  as  are  debilitated  by  excesses  of  any 
kind — by  gout,  syphilis,  scurvy,  cancer,  and,  most  of  all,  by 
years. 

Sect.  V. — Chronic  Pleurisy. 

There  are  three  kinds  of  chronic  pleurisy ;  1st.  that  which  is 
chronic  from  its  origin  ;  2nd.  acute  pleurisy  become  chronic ; 
3rd.  pleurisy  complicated  with  certain  organic  productions  on  the 
surface  of  the  pleura,  bearing  a  gross  resemblance  to  cutaneous 
eruptions.  I  shall  not  notice  this  last  variety  in  the  present 
chapter. 

Anatomical  characters.  Chronic  pleurisy  does  not  differ  essen- 
tially, in  its  anatomical  characters,  from  the  acute.  In  the  chronic 
disease,  the  pleura  is  commonly  of  a  deeper  red,  and  the  serous 
effusion  is  more  abundant  and  almost  always  less  limpid,  being 
mixed  with  a  great  quantity  of  very  small  albuminous  flocculi. 
The  abundance  and  minuteness  of  these  are  sometimes  so  consi- 
derable, as  to  render  the  liquid  quite  puriform,  even  when  left 
undisturbed.  More  commonly,  the  serum  is  of  a  lemon  color, 
although  still  less  limpid  than  in  the  acute  disease,  and  thickly 
intermixed  with  the  small  fragments,  just  mentioned,  which,  like 
coarse  flour  diffused  through  water,  fall  to  the  bottom  when  at 
rest.  In  such  cases,  these  puriform  fragments  accumulate  in 
great  quantity  in  the  most  depending  parts  of  the  thoracic  cavity, 
and  by  their  consistence  form  a  link  between  the  sero-purulent 
effusion  and  the  false  membranes.  These  latter  never  have  the 
consistence  of  boiled  white  of  egg  as  in  the  acute  pleurisy.  We 
break  them  with  the  greatest  facility  in  detaching  them  from  the 
pleura ;  they  are  friable  between  the  fingers,  and  sometimes  their 
cohesion  is  so  slight  that  we  might  mistake  them  for  a  deposition 
of  the  thicker  parts  of  the  pus.  The  extravasated  fluids  in 
chronic  pleurisy  are  rarely  so  free  from  smell  as  in  the  acute ; 
sometimes  they  have  a  heavy  odor,  more  disagreeable  than  that 


iS4  CHRONIC    PLEURISY. 

of  healthy  pus,  or  a  strong  alliaceous  odor,  analogous  to  that  of 
gangrene.*  Confining  the  term  chronic  pleurisy  to  the  affection 
just  described,  and,  therefore,  not  even  including  those  cases  ol 
acute  pleurisy  which  are  chronic  in  respect  of  their  length  of 
duration,  we  may  say  that  the  disease  has  rarely  any  natural  ten- 
dency towards  resolution.  Tn  cases  of  extravasation  which  have 
lasted  several,  months,  we  frequently  find  no  mark  of  any  step 
towards  the  conversion  of  the  false  membranes  into  cellular  sub- 
stance. A  cure,  however,  is  sometimes  effected  in  another  man- 
ner, as  wjll  be  shown  presently. 

The  effusion  produced  by  chronic  pleurisy  tends,  most  com- 
monly, to  become  daily  more  considerable.  The  affected  side 
becomes  manifestly  larger  ;  the  intercostal  spaces  grow  broader, 
and  rise  to  a  level  with  the  ribs,  and  sometimes  even  higher. 
The  lung  of  the  affected  side,  compressed  towards  the  medias- 
tinum and  spine,  and  retained  in  this  position  by  the  pseudo- 
membranous exudation  which  covers  it  completely,  is  sometimes 
reduced  to  so  small  a  size,  as  to  be  hardly  from  four  to  six  lines 
thick,  even  in  its  middle ;  and  without  a  careful  examination, 
might  be  considered  as  totally  destroyed.  In  this  state,  the  pul- 
monary tissue  is  soft,  supple,  and  dense  like  a  piece  of  skin,  with- 
out any  crepitation,  more  pale  than  natural,  greyish,  and  almost 
entirely  without  blood.  Its  blood-vessels  are  flattened,  and  fre- 
quently appear  quite  empty.  The  alveolar  texture  is  neverthe- 
less still  very  distinct.  This  case  constitutes  the  most  common 
species  of  empyema,  the  purulent  empyema  of  surgeons,  or,  at 
least,  of  modern  surgeons ;  for  I  apprehend  no  one  now  consid- 
ers empyema  as  the  product  of  a  vomica  which '  has  burst  into 
the  cavity  of  the  pleura.  A  softened  tubercle  may,  indeed,  dis- 
charge its  contents  in  this  manner,  and  may  thus  become  the 
cause  of  a  considerable  effusion,  by  exciting  a  chronic  pleurisy, 
but  in  such  a  case  the  tuberculous  matter  must  only  be  con- 
sidered in  the  light  of  an  extraneous  body  determining  inflam- 
mation, and  consequent  effusion,  by  its  mechanical  or  chemical 
qualities.  It  is  also  to  this  species  of  pleurisy  that  we  must  refer 
those  histories  of  lungs  entirely  destroyed  by  suppuration  winch 
we  find  recorded  in  the  older  writers. 


The  great  and  peculiar  fetor  of  the  expectoration,  has  beeta  considered  by 
dome  writers  as  almost  characteristic  of  the  communication  between  the  bron- 
chi and  tlic  sac  of  the  pleura,  ill  eases  of  chronic  pleurisy.  Some  have  com- 
pared this  odor  10  garlic,  some  to  thai  of  phosphorated  hydrogen,  and  others  to 
other  ill  smells.  See  Andrei's  Clin.  Med.  t.  Li.'  p.  561.  Professor  Nespoli,  in 
an  ingenious  pamphlel  on  the  diagnosis  of  disi  ases  of  the  chest,  published  at 
Florence  in  ES25,  dwells  a  good  deal  on  this  sign.  Sec  his  Discorso  reeitato  ml 
riaprireil  corso,  <fcc.  1825.  This  author  describes  the  expectoration  in  such 
eases  as  having  "  Podor.e  di  assafctida  ma  assai  piu  di  ijuesta  penetrante  e 
■acido."  ji.  25. —  Transl. 


CHRONIC    PLEURISY. 


485 


There  is  still  another  variety  of  chronic  pleuritic  effusion  ; 
although  it  is  of  rare  occurrence.  In  this,  the  serosity  is  greenish, 
and  the  pus  of.  a  yellowish  color,  and  of  a  degree  of  consistence 
very  like  that  of  certain  sputa.  This  variety  is  especially  flJund 
in  cases  wherein  the  effusion  is  scanty  and  confined,  on  account 
of  previous  adhesions.  This  species  of  pus  has  a  greater  ten- 
dency to  be  converted  into  the  accidental  tissue,  than  that  for- 
merly described.  Sometimes,  even,  I  have  seen  its  thickest  parts 
already  divided  into  irregular  spaces,  like  those  of  cellular  sub- 
stance. Occasionally  the  effusion  of  the  chronic,  as  well  as  of 
the  acute  pleurisy,  finds  its  way  into  the  bronchi,  or  through  the 
walls  of  the  chest. 

Signs  and  symptoms. — The  physical  signs  of  chronic  pleurisy 
differ  in  no  respect  from  those  of  the  acute,  with  this  exception, 
that  we  rarely  meet  with  this  segophony  in  the  former,  because 
the  effusion  is  almost  always  abundant  before  the  patient  deter- 
mines to  consult  the  physician.  The  disease  usually  begins  in  an 
insidious  manner.  Either  the  stitch  does  not  exist  at  all,  or  it  is 
obscure,  momentary,  and  felt  after  long  intervals.  A  slow  fever 
creeps  on  by  degrees ;  there  is  cough,  and,  more  frequently  than 
in  the  acute  disease,  the  cough  is  attended  by  a  mucous,  some- 
times even  by  a  puriform  expectoration.  Emaciation  proceeds 
with  more  or  less  rapidity  ;  the  digestive  functions  become  disor- 
dered ;  frequently  the  sensibility  of  the  stomach  is  at  times  so 
much  increased,  that  the  patient  can  hardly  bear  not  merely  the 
lightest  food,  but  not  even  drink.  Sometimes  a  puriform  expec- 
toration comes  on  all  at  once,  and  is  so  copious  as  to  lead  to  the 
apprehension  that  the  pus  has  made  its  way  into  the  bronchi. — 
This  appearance  may  be  repeated  several  times  in  the  twenty- 
four  hours  ;  and  it  is  observed,  in  many  cases,  where  there  exists 
no  communication  with  the  bronchi. 

Chronic  pleurisy  constitutes,  as  stated  above,  the  purulent  em- 
pyema of  surgeons.  Although  its  presence  indicates  a  more  un- 
favorable state  of  the  constitution  than  exists  in  the  acute  dis- 
ease, it  affords  a  more  favorable  chance  for  the  success  of  the 
operation  of  empyema.  The  chief  obstacle  to  the  success  of  this 
operation,  in  the  acute  disease,  consists  in  the  difficulty  which  the 
lung  finds  to  unfold  itself  to  its  former  dimensions,  bound  down, 
as  it  is,  and  compressed  against  the  spine  and  mediastinum,  by  the 
false  membranes.  Now,  in  the  case  of  the  chronic  disease,  this 
obstacle  does  not  exist,  since  in  it  there  are  either  no  false  mem- 
branes, or  they  are  soft,  friable,  and  seemingly  formed  of  the 
thicker  portion  of  the  purulent  fluid. 

The  true  chronic  pleurisy  is  essentially  chronic.  At  no  period 
of  its  course  does  it  present  the  intense  fever,  severe  pain,  or 
energetic  re-action,  which  characterize  an  acute  disease.     It  only 


486  CHRONIC    PLEURISY. 

attacks  persons  who  have  become  cachectic  from  some  cause  or 
other,  and  particularly  in  consequence  of  a  tuberculous  affection 
of  the  lungs.*  The  complication  just  named,  as  well  as  the  mod- 
erate degree  of  the  local  and  general  symptoms,  conspire  to 
make  it  most  commonly  latent.  Hence  it  has  almost  always  been 
confounded  with  phthisis  pulmonalis.f 

The  acute  pleurisy  become  chronic,  differs  from  the  preceding 
variety  in  some  essential  points.  The  disease  assumes  this  course 
whenever  any  thing  interferes  with  the  speedy  absorption  of  the 
effused  fluid,  and  the  conversion  of  the  false  membrane  into  the 
adventitious  serous  tissue  ;  and  the  cause  of  this  interruption  is, 
in  general,  a  state  of  debility  or  cachexy,  originating  in  some 
complication  anterior  or  posterior  to  the  pleuritic  attack.  The 
extreme  abundance  of  the  effusion  is  one  of  the  circumstances 
from  which  we  may  most  certainly  augur  that  the  disease  will  be- 
come chronic,  if  indeed  it  does  not  prove  fatal  in  the  acute  stage. 
The  hemorrhagic  pleurisy,  as  already  stated,  most  constantly  af- 
fects this  course.  The  transition  from  the  acute  to  the  chronic 
state  is  announced  by  the  gradual  diminution  of  the  fever.  This 
is  at  times  entirely  absent,  but  almost  constantly  re-appears  to- 
wards evening ;  and  every  now  and  then,  from  some  slight  error 
of  regimen,  or  without  any  appreciable  cause,  it  becomes  intense. 
With  these  exceptions,  the  greater  number  of  the  animal  func- 
tions exhibit  no  disorder;  in  many  cases  there  is  even  no  dysp- 
noea, when  the  patient  is  quiet.  The  digestion  is  often  good  ;  but 
the  stomach  is  more  delicate  than  in  health :  it  can  only  receive  a 
small  portion  of  food  at  a  time ;  and  when  the  patient  happens  to 
have  a  good  appetite  (which  is  by  no  means  uncommon)  and  in- 
dulges in  it,  he  is  frequently  affected  with  vomiting,  diarrhoea,  or, 
at  least,  by  uneasy  digestion. 

The  physical  signs  of  this  variety  are  nearly  the  same  as  of 

*  I  have  seen  in  many  cases,  chronic  pleurisy,  which  had  this  character  from 
the  beginning,  attack  persons  who,  up  to  that  period,  had  enjoyed  perfect  health, 
and  who  were  by  no  means  in  a  state  of  cachexy  ;  they  had  for  some  days  a 
pain  in  the  side,  which  t-hey  disregarded,  as  being  nervous  or  rheumatic;  they 
had  no  cough  or  fever,  did  not  desist  from  business,  and  .a  few  days  after  the 
attack  of  this  pain,  auscultation  and  percussion  discovered  an  effusion  in  the 
pleura. — Andral. 

t  True  chronic  pleurisy  is  a  very  common  disease  ;  and  there  are  few  more 
deserving  the  particular  attention  of  practitioners.  It  is,  as  our  author  observes, 
almost  always  confounded  with  phthisis  pulmonalis.  Many  examples  of  this 
mistake  could  be  cited  from  our  periodical  literature,  and  still  more  could  be 
furnished  by  every  pathological  practitioner  of  experience.  Sometimes,  how- 
ever, it  is  entirely  overlooked  as  a  pectoral  affection.  For  several  interesting 
examples  of  this  disease  I  refer  to  my  "  Original  Cases,"  &c. ;  and  for  some 
admirable  remarks  on  the  diagnosis  between  it  and  phthisis,  I  refer  the  reader 
to  Broussais's  Phleg.  Chron.  t.  ii.  p.  203.  One  of  the  most  striking  of  the  gene- 
ral diagnostic  symptoms  there  mentioned,  and  which  I  have  frequently  observed, 
is  the  return  of  the  pulse  to  the  natural  frequency  after  rest,  particularly  after 
a  night's  rest,  in  the  pleuritic  affection.—  Transl. 


CONTRACTION    OF    THE    CHEST.  487 

the  preceding.  yEgophony  is  no  longer  perceptible  after  the 
effusion  has  become  considerable  ;  and  it  rarely  re-appears  upon 
the  diminution  of  this,  as  in  the  acute  disease  when  a  speedy 
resolution  takes  place,  owing  to  the  destruction  of  the  elasticity 
and  tonicity  of  the  bronchi,  occasioned  by  the  long  compression 
of  the  lung.  For  the  same  reason,  the  respiratory  sound  is  long 
in  returning,  at  least  in  the  lower  parts  of  the  lungs.  In  the 
upper  parts  it  frequently  returns  before  the  dilatation  of  the  chest 
is  at  all  diminished.  A  cure  in  this  affection  is  not  common, 
and  certainly  does  not  take  place  in  more  than  half  the  cases. 
Death  in  general  does  not  ensue  before  the  occurrence  of  great 
emaciation  ;  and  it  is  accelerated  by  the  supervention  of  anasarca, 
or  sanguineous  or  serous  congestions  in  the  brain,  or  of  slight  in- 
flammations of  the  lungs,  which  organs  had  hitherto  continued 
healthy.  When  the  anasarca  becomes  general,  it  is  greatest  in 
the  arm  and  leg,  and  also  on  the  trunk,  of  the  diseased  side. 

Sect.    VI. — Contraction  of  the   Chest,  consequent  to  certain 

Pleurisies. 

There  are  some  cases  of  pleurisy  wherein  the  affected  side 
never  becomes  sonorous  in  the  trial  of  percussion,  although  the 
disease  has  been  completely  cured  and  the  effused  fluid  absorbed. 
Although  cases  of  this  sort  are  not  very  rare,  they  have  not 
hitherto  attracted  sufficiently  the  attention  of  practitioners  ;  and 
I  apprehend  that  the  pathological  character  of  the  affection,  al- 
though noticed  by  several  authors,  has  not  as  yet  been  correctly 
or  completely  described.  The  subjects  of  this  morbid  alteration 
are  sufficiently  distinguishable  even  by  their  external  shape,  and 
by  their  gait.  They  seem  constantly  to  lean  towards  the  affected 
side.  This  is  always  manifestly  narrower  than  the  opposite  side, 
there  being  frequently  more  than  an  inch  of  difference,  when  they 
are  both  measured  by  means  of  a  cord.  The  length  of  the  chest 
is  equally  diminished  :  the  ribs  are  closer  to  one  another ;  the 
shoulder  is  lower ;  and  the  muscles,  especially  the  pectoral,  are 
only  half  the  size  of  those  of  the  opposite  side.  The  difference 
of  the  two  sides  is  so  remarkable,  that,  at  first  sight,  we  would 
think  it  much  greater  than  it  is  found  to  be  by  admeasurement. 
The  spinal  column  generally  remains  straight ;  sometimes,  how- 
ever, it  at  length  yields  through  the  effect  of  habitual  leaning 
towards  the  diseased  side.  This  habit  gives  to  the  individual 
the  appearance  of  being  somewhat  lame.  The  greater  plumber 
of  individuals  in  whom  I  have  detected  this  deformity,  attributed 
it  to  some  severe  and  long  •  continued  disease  of  the  chest,  the 
exact  character  of  which  had  never  been  ascertained  :  some  had 
well-marked  attacks  of  pleurisy  or  pneumonia  of  long  standing. 


IQQ  CONTRACTION    Of    THE    CHEST. 

I  have  more  than  #  once  pointed  out  this  alteration  of  the  form  of 
the  chest  to  individuals,  in  whom  it  existed  in  a  great  degree, 
who  were  not  themselves  at  all  aware  of  its  existence.  All  of 
these  had  experienced  a  disease  of  long  duration,  the  principal 
seat  of  which  had  seemed  to  be  in  the  thorax  :  but  in  several  the 
affection  appeared  to  have  been  only  slight. 

I  had  long  observed  this  contraction  of  the  chest  before  I  had 
an  opportunity  of  proving,  by  dissection,  the  particular  lesion  to 
which  it  was  owing.  I  attended  a  patient  for  several  years,  in 
whom  it  had  existed  in  the  greatest  degree  for  fifteen  years.  He 
was  subject  to  a  chronic  catarrh,  and  was  so  short-breathed  that 
he  might  be  considered  as  asthmatic.  In  this  instance,  however, 
it  is  probable  that  the  dyspnoea  was  more  owing  to  the  catarrh 
than  the  deformity  of  the  chest ;  as,  in  the  greater  number  of 
cases  in  which  I  have  observed  this  state,  although  the  respiration 
was  shorter  than  usual,  still  it  could  not  be  considered  as  amount- 
ing to  habitual  dyspnoea.  A  remarkable  instance  of  this  is  fur- 
nished in  his  own  person  by  M. ,  a  very  distinguished  sur- 
geon of  Paris.  In  this  gentleman,  the  left  side  of  the  chest  has 
been  contracted  ever  since  an  attack  of  pleurisy  in  his  youth. 
It  yields  a  completely  dull  sound  on  percussion  on  the  lower  and 
lateral  parts  ;  but  the  respiratory  sound  is  distinct,  only  some- 
what weaker  than  on  the  other  side.     M. enjoys  excellent 

health :  he  has  a  strong  and  sonorous  voice,  and  has  for  several 
years  past  delivered  lectures,  sometimes  two  in  one  day,  each  of 
an  hour,  without  inconvenience.  Six  or  seven  years  since,  he 
had  a  very  severe  attack  of  fever,  in  which  the  respiration  did  not 
suffer  more  than  in  persons  in  general. 

Cases  of  very  great  contraction  are  rare  :  but  those  in  which 
the  alteration  of  the  shape  and  the  decrease  of  resonance  on  per- 
cussion are  only  slight,  are  very  common.  This  contraction, 
when  strongly  marked,  coincides  always  with  the  formation  of 
the  adventitious  fibro-cartilaginous  membranes  formerly  de- 
scribed. The  cause,  no  doubt,  of  this  lesion  having  been  so  long 
unknown,  is  its  dependence  on  so  obscure  a  disease  as  the  haemor- 
rhagic  pleurisy.  The  symptoms  of  this  affection  are  indeed, 
very  variable,  and  its  progress  very  irregular.  In  its  commence- 
ment, it  has  frequently  no  resemblance  to  the  simple  acute  pleu- 
risy :  and  it  is  truly  better  entitled  to  the  name  of  latent,  than 
any  other  variety.  In  it,  the  pain  is  infrequent,  temporary,  and 
often  so  trifling  as  not  to  be  mentioned  by  the  patient,  unless 
questioned  respecting  it.  The  dyspnoea  is  sometimes  very  slight ; 
the  cough  infrequent  and  dry.  Sometimes,  however,  particularly 
in  asthmatic  persons  and  in  those  subject  to  catarrh,  there  is 
much  dyspnoea,  and  a  more  or  less  abundant  expectoration  ;  but 
in   cases  of  this  kind,  the  whole  complexion  of  the  disease  is 


CONTRACTION    OF    THE    CHEST. 


489 


rather  that  of  catarrh  or  asthma,  than  of  pleurisy.  In  short, 
in  many  cases,  one  would  be  misled  by  the  symptoms  to  look  for 
the  site  of  the  disease  any  where  else,  rather  than  in  the  chest. 
A  state  of  languor  and  extreme  debility,  a  slight  degree  of  fever, 
a  loss  of  appetite  disproportioned  to  the  apparent  mildness  of  the 
disease,  are  frequently  the  only  symptoms.  The  cough  is  so 
inconsiderable,  as  to  be  frequently  overlooked  both  by  the  patient 
and  the  physician. 

In  cases  of  this  kind,  the  stethoscope  and  percussion  afford 
the  only  means  of  ascertaining  the  nature  of  the  disease.  By 
itself,  indeed,  percussion  will  only  enable  us  to  suspect  the  pre- 
cise nature  of  the  affection,  as  the  absence  of  sound  may  be  owing 
to  infarction  of  the  lung  as  well  as  effusion  into  the  chest ;  but 
when  conjoined  with  auscultation,  which  will  detect  the  respi- 
ratory sound  at  the  roots  of  the  lungs  only,  the  nature  of  the  case 
will  be  at  once  evident.  The  contraction  of  the  chest,  which 
coincides  with  the  absorption  of  the  serous  portion  of  the  effusion, 
begins  at  an  early  period  of  the  disease  ;  but  it  is  often  not  very 
perceptible  until  after  several  months ;  and,  frequently  even,  the 
patient  has  long  been  in  a  state  of  doubtful  convalescence  before 
it  is  at  all  manifest..  At  length,  however,  after  a  long  period  of 
ill  health,  sometimes  of  no  less  duration  than  two  or  three  years, 
the  strength,  appetite,  &c.  return,  and  the  patient  regains  perfect, 
and  in  many  cases,  permanent  health.  The  affected  side,  never- 
theless, still  yields  a  dull  sound — frequently  the  complete  fleshy 
sound — on  percussion :  and  the  respiratory  sound  is  commonly 
weaker  than  natural  over  the  whole  of  it,  and  in  the  lower  parts 
it  is  either  not  perceived  at  all,  or  it  is  extremely  indistinct.  On 
examining  the  chest  of  those  who  had  this  contraction  in  a  very 
decided  manner,  I  have  uniformly  found  the  fibro-cartilaginous 
adhesions  above  described,  and  the  lung  so  compressed  and  flac- 
cid, as  to  have  the  appearance  of  muscular  substance,  of  which 
the  fibres  are  so  fine  as  to  be  undistinguishable.  Sometimes  the 
compressed  lung  is  as  red  as  muscle  ;  at  other  times,  it  is  of  a 
grey  color,  somewhat  deeper  but  less  transparent  than  the  mus- 
cles of  fishes.  This  last  I  consider  as  the  proper  color  of  lung 
simply  compressed,  and  imagine  the  red  color  to  be  owing  to  a 
passive  congestion  of  blood  in  the  part,  like  what  occurs  after 
death. 

The  absence  of  the  respiratory  sound  in  the  case  of  contraction 
of  the  chest,  is  not,  as  might  be  imagined,  owing  to  the  thickness 
of  the  adventitious  membranes.  Even  in  the  acute  pleurisy, 
with  the  most  copious  effusion,  it  is  not  the  mere  distance  of  the 
lung  from  the  side,  that  occasions  the  failure  of  the  sound  of 
respiration.  This  is  proved  by  the  fact,  that  the  greatest  degree 
of  fatness,  the  size  of  the  female  breast,  the  anasarcous  state  of 
62 


490  CONTRACTION    OF    THE    CHEST. 

the  integuments,  or  thick  clothing,  do  not  sensibly  diminish  the 
sound,  when  it  is  considerable  ;  whilst,  on  the  other  hand,  it  is 
hardly  at  all  perceptible  even  in  the  leanest  subjects,  when  they, 
either  naturally  or  from  nervous  apprehension  under  the  first  ap- 
plication of  the  stethoscope,  breathe  in  an  imperfect  manner.  It 
is,  therefore,  evident  in  these  cases,  that  the  diminution  or  ab- 
sence of  the  respiratory  sound,  is  much  more  owing  to  the  im- 
perfect dilatation  of  the  air-cells,  than  the  thickness  of  the  com- 
pressing body.  In  the  less  severe  cases  of  this  nature,  and  when 
the  contraction  of  the  chest  is  not  very  considerable,  after  the 
complete  conversion  of  the  false  membrane  into  the  cartilaginous 
substance,  the  respiration  returns  in  a  slight  degree  in  the  affected 
side,  but  less  strongly  than  in  the  opposite  one.  As  an  instance 
how  long  it  may  be  before  this  variety  of  pleurisy  is  completely 
terminated,  I  may  state,  that,  in  the  patient  from  whose  chest  I 
had  some  drawings  made,  it  was  not  until  two  years  and  a  half, 
to  reckon  from  the  invasion  of  the  disease,  or  a  year,  to  reckon 
from  the  period  of  his  convalescence,  that  I  began  to  perceive  a 
slight  sound  of  respiration  below  the  clavicle  and  on  the  upper 
part  of  the  back.  In  certain  cases,  the  respiration  becomes  good 
over  the  superior  parts  of  the  chest,  without  being  at  all  restored 
on  the  inferior ;  and  this  may  be  owing  to  the  fibro-cartilaginous 
membrane  not  extending  to  the  upper  lobe :  and  in  all  cases, 
even  where  the  respiration  is  perceptible  in  some  degree  over  the 
whole  chest,  it  is  always  stronger  in  this  situation. 

However  weak  and  imperfect  the  respiration  may  be  in  a  lung 
compressed  in  this  manner,  the  contraction  of  the  chest  must, 
nevertheless,  be  considered  as  a  mode  of  cure.  In  the  cases 
where  it  exists  in  the  greatest  degree,  it  does  not  always  render 
the  individual  an  invalid,  but  may  even  be  compatible  with  a  con- 
siderable degree  of  general  vigor.  It,  moreover,  takes  away 
every  apprehension  of  a  relapse ;  for  if,  as  we  have  already  said, 
pleurisy  is  very  rare  in  the  cases  of  cellular  union  of  the  lungs 
and  pleura,  it  must  be  considered  as  almost  impossible  when  the 
union  is  effected  by  means  of  a  tissue  so  little  disposed  to  inflam- 
mation, as  is  the  fibro-cartilaginous. 

Although  in  all  the  cases  I  have  met  with  of  decided  contrac- 
tion of  the  chest,  I  have  found  the  lung  attached  by  means  of- 
the  fibro-cartilaginous  membranes  above  described,  closely  united 
to  one  another  by  a  cellular  tissue  of  subsequent  formation ;  I 
am,  nevertheless,  of  opinion,  that  the  contraction  may  be  found 
in  an  equal  degree,  subsequently  to  a  pleurisy  which  has  termi- 
nated very  slowly  with  the  formation  of  merely  cellular  adhesions. 
Indeed,  in  every  case  wherein  I  have  found  one  lung  adherent 
throughout,  by  means  of  a  pretty  copious  cellular  tissue,  I  have 
always  thought  this  side  of  the  chest  narrower  than  the  other. 


CONTRACTION    OF    THE    CHEST. 


491 


I  may  add  that  this  condition  of  parts  is  so  constant,  that  it  is 
surprising  the  morbid  alteration  of  shape  we  are  now  considering 
had  not  before  attracted  the  notice  of  anatomists.  The  difference 
between  the  sides  is  particularly  observable  after  both  lungs  are 
removed.  I  had  noticed  this  circumstance  when  I  was  a  student, 
and  before  I  had  ascertained  that  the  smaller  side  was  always 
that  in  which  the  adhesions  existed,  or  in  which  they  were  most 
considerable.  I  mentioned  the  thing  to  one  of  my  teachers,  and 
was  informed  that  this  inequality  of  size  was  owing  to  an  original 
malformation. — When  both  lungs  are  adherent,  the  chest  is 
generally  very  narrow ;  and  the  resonance  on  percussion  is  im- 
perfect even  when  the  sound  of  respiration  is  pretty  good.  With 
all  this,  it  must  be  admitted,  that  these  cellular  adhesions,  even 
when  very  extensive,  have  no  bad  effect  on  the  respiration  and 
general  health  ;  almost  every  adult  subject  having  these,  as  it  is 
well  known,  in  a  greater  or  less  degree. 

In  the  case  of  large  pulmonary  abscesses,  or  extensive  or  nu- 
merous tuberculous  excavations,  the  containing  parts  begin  gra- 
dually to  collapse  shortly  after  the  discharge  of  the  matter,  and 
the  walls  of  the  chest  follow  the  retrocession  of  the  soft  parts. 
This  partial  contraction,  which  is  chiefly  found  on  the  upper  and 
anterior  parts,  is  very  perceptible  after  the  cicatrization  is  com- 
plete. Bayle  made  the  observation  that  the  chest  seemed  to  be 
contracted  in  the  case  of  phthisis  of  long  standing,  but  he  does 
not  seem  to  have  been  acquainted  with  the  cause  of  it.  In  the 
case  of  phthisis  this  cause  is  usually  twofold  ;  depending  no  less 
on  the  contraction  of  the  tuberculous  excavations,  than  on  the 
latent  or  manifest  pleurisies,  with  which  these  are  commonly  com- 
plicated. 

From  what  has  gone  before,  it  results,  that  it  is  not  to  the 
adhesions  themselves  that  we  are  to  attribute  the  contraction  of 
the  chest,  but  to  the  more  or  less  chronic  manner  of  their  de- 
velopment ;  and,  further,  we  may  conclude  that  the  more  rapid 
has  been  the  absorption  of  the  effusion,  the  less  fear  is  there  of 
any  contraction  ensuing.  In  fact,  the  longer  the  lung  has  been 
retained  in  a  state  of  compression,  the  greater  is  its  loss  of  nat- 
ural elasticity  ;  and  in  this  respect  it  is  merely  in  accordance 
with  other  ^rgans ;  a  muscle  long  compressed  by  a  bandage  is  in 
a  like  predicament.  The  bony  compages  of  the  chest  necessarily 
contract  as  the  effusion  is  diminished,  and  exactly  in  the  same 
degree,  unless  the  lungs  are  proportionally  expanded :  there  can- 
not remain  a  vacuum  in  any  part  of  the  animal  body.  In  pleu- 
risies accompanied  with  a  copious  extravasation,  and  whose  reso- 
lution is  consequently  slow,  the  contraction  of  the  affected  side  is 
almost  always  very  discoverable  by  the  eye  and  by  mensuration^ 
very  long  before  the  complete  absorption  of  the  fluid. 


492  CONTRACTION    OF    THE    CHEST. 

As  the  affection  now  treated  of  is  very  little  known,  I  shall 
subjoin  four  cases  of  it.  The  first  and  second  of  these  exhibit  the 
disease  at  its  termination ;  the  third  points  out  the  progressive 
stages  as  well  as  the  state  of  the  affected  parts,  very  near  its  close  : 
the  fourth  is  an  example  of  the  hemorrhagic  pleurisy,  which 
would  have  terminated  in  the  same  manner  if  a  cure  had  been  ef- 
fected. 

Case  XXXI. — Contraction  of  the  chest  in  a  consumptive 
patient.  A  woman,  aged  about  thirty-seven,  came  into  the'Necker 
Hospital  in  May,  1818.  She  had  been  affected  with  cough  for 
several  years,  but  more  severely  within  the  last  four  months. 
She  was  in  a  state  of  great  emaciation,  and  was  decidedly  hectic. 
The  voice  resounded  strongly  beneath  the  clavicle  and  in  the 
axilla  of  the  right  side,  but  did  not  traverse  the  stethoscope — 
(bronchophony  from  congregated  tubercles.)  Over  the  same 
points,  there  was  a  strong  guggling  rhonchus,  indicative  of  the 
transmission  of  air  through  the  softened  tubercles  (cavernous 
rhonchus.)  The  sputa  were  yellow,  opaque,  puriform,and  some- 
what diffluent.  It  being  apparent  from  these  results  that  this 
was  a  case  of  hopeless  consumption,  the  patient  was  not  more 
particularly  examined  afterwards  ;  except  that,  on  the  19th,  pec- 
toriloquy was  found  very  distinct  in  the  right  axilla.  She  died 
on  the  24th. 

Dissection. — Upon  inspecting  the  body  after  death,  the  left 
side  of  the  chest  was  found  to  be  evidently  diminished  in  all  its 
dimensions  ;  the  intercostal  spaces  were  so  much  contracted  that 
the  ribs  seemed  to  touch  each  other.  The  right  side  was  of 
natural  form  and  size,  and  appeared  larger  than  the  other  by 
one-half.  This  deformity  had  not  "been  observed  during  life, 
owing  to  the  patient's  clothing.  The  right  lung  adhered  to  the 
diaphragm  and  the  mediastinum,  in  its  whole  extent,  by  well 
organized  cellular  adhesions.  In  the  superior  lobe  there  was 
one  tuberculous  excavation  capable  of  containing  a  small  pullet's 
egg.  In  it  there  were  about  two  spoonfuls  of  tuberculous  matter 
of  the  consistence  of  pus.  In  the  same  upper  lobe,  there  were 
several  other  lesser  cavities,  still  filled  with  tuberculous  matter, 
softened  to  the  same  degree  ;  and  also  many  crude  tubercles. 
The  left  lung  was  one-half  less  than  the  right ;  it  w^  depressed 
towards  the  spine  and  ribs,  so  that  its  internal  surface  was  turned 
forwards,  yet  did  not  reach  further  than  the  origin  of  the  carti- 
lages, and  did  not  at  all  cover  the  heart :  it  adhered  so  firmly  to 
the  ribs  that  it  could  not  be  separated  without  detaching  it'  from 
its  investing  pleura.  This  adhesion  was  effected  by  the  medium 
of  a  substance  altogether  similar,  in  texture,  color,  and  consist- 
ence, to  the  fibro-cartilaginous  bodies.  This  substance  was  about 
two  lines  in  thickness,  and  was  divided  into  two  layers,  which 


CONTRACTION    OF    THE    CHEST. 


493 


were  separated  from  each  other  by  a  third,  much  thinner.  This 
was  of  a  bluish  grey  color  and  semi-transparent, — qualities  which 
formed  a  contrast  with  the  whiteness  and  opacity  of  the  others. 
The  intermediate  layer  resembled  perfectly  the  transparent  central 
portion  of  the  intervertebral  fibro-cartilages  ;  it  was  less  solid  than 
the  other  two,  yet  possessed,  with  them,  the  fibrous  structure. 
The  pleura  pulmonalis  and  costalis,  especially  the  former,  were 
very  distinct,  exteriorly  to  these  false  membranes.  The  pulmo- 
nary tissue,  more  flaccid,  and  redder  than  natural,  had  lost  its 
crepitans  feel,  and  was  of  the  aspect,  and  consistence  of  muscle. 
In  the  upper  lobe  there  was  a  tuberculous  excavation  capable  of 
holding  a  large  walnut,  and,  like  that  on  the  other  side,  was  lined 
by  a  soft  and  whitish  membrane. 

Case  XXXII. — Contraction  of  the  chest  subsequent  to  chro- 
nic pleurisy,  with  the  supervention  of  fatal  acute  pleurisy.  In 
Marfch,  1818,  a  man,  aged  eighteen,  came  into  the  Necker  Hos- 
pital, affected  with  recent  diarrhoea  and  a  complaint  of  the  chest 
of  some  standing.  In  the  winter  of  1816  he  had  been  affected 
with  a  viofent  cold,  attended  by  severe  cough,  much  dyspnoea, 
and  a  great  pain  on  the  left  side.  This  side  of  the  chest  was  now 
evidently  smaller  than  the  right  in  every  dimension ;  and  the 
shoulder  being  thereby  lower,  the  man  had  the  appearance  of 
being  lame.  He  bent  the  left  leg  more  than  the  right,  and  when 
he  stood  upright  he  seemed  to  support  himself  on  his  left  hip. 
This  side  yielded  a  dull  sound  on  percussion,  and  the  sound  of 
respiration  was  scarcely  audible,  except  very  feebly  below  the 
second  rib  and  along  the  spine.  The  right  side,  on  the  contrary, 
sounded  well  on  percussion,  and  afforded  perfect  respiration 
under  the  stethoscope.  The  diagnostic  was  here  given — Diar- 
rhoea, in  a  person  cured  of  pleurisy  by  adhesion  of  the  lungs  to 
the  pleura  by  means  of  a  fibro-cartilaginous  membrane.  For 
the  first  month  after  this  man's  admission,  .he  remained  much  in 
the  same  state.  In  the  succeeding  month,  his  health  improved. 
The  diarrhoea  ceased  ;*  the  slight  cough  which  he  had  had,  dis- 
appeared, and  the  appetite  and,  in  some  degree,  the  strength, 
returned.  The  respiratory  sound  became  much  more  perceptible 
at  the  roots  of  the  left  lung  and  on  the  upper  and  fore  part  of 
the  chest  on  the  same  side,  where,  indeed,  it  was  very  distinct 
from  the  clavicle  to  the  fourth  rib,  only  weaker  than  on  the  op- 
posite side.  In  May  the  diarrhoea  returned,  and  he  was  also 
attacked  with  a  slight  pain  of  the  right  side  of  the  chest,  which 
yielded  to  the  application  of  leeches.  He  from  this  time  gradually 
got  worse ;  and  well-marked  symptoms  of  chronic  peritonitis 
were  added  to  those  already  existing,  with  great  aggravation  of 
suffering  and  loss  of  strength.  On  the  12th  July,  he  was  further 
seized    with   a   very  violent   and    sharp  pain  in   the   right   side, 


494  CONTRACTION    OF    THE    CHEST. 

aggravated  by  cough  and  deep  inspirations.  The  chest  was 
again  examined  at  this  time.  On  the  left  side,  anteriorly,  the 
respiratory  sound  was  distinct  and  of  moderate  strength  from  the 
clavical  to  the  fourth  rib ;  and,  posteriorly,  from  the  top  of  the 
shoulder  to  the  sixth  rib :  it  was  also  beginning  to  be  perceptible 
on  the  lower  parts  of  this  side.*  Now,  however,  it  was  no  longer 
perceptible  over  the  whole  of  the  right  side,  except  between  the 
clavicle  and  the  second  rib,  along  the  sterno-costal  cartilages : 
and  even  in  these  points  it  was  much  less  than  in  the  upper  part 
of  the  left  side.  On  the  right  back  it  was  more  perceptible,  but 
intermixed  with  a  slight  rhonchus  ;  and  exactly  at  the  roots  of 
the  lung  on  this  side,  it  was  louder  than  in  any  other  part  of  the 
chest.  After  this  exploration  the  following  addition  was  made 
to  the  diagnostic — Recent  pleuro-pneumonia  of  the  right  side; 
the  effusion  not  yet  very  considerable,  but  in  greatest  quantity 
in  the  lateral  parts  of  the  cavity  of  the  pleura.  On  the  14th, 
the  pain  of  the  side  was  nearly  gone  ;  but  the  cough  was  severe, 
and  the  expectoration  yellow,  frothy,  but  not  adhesive  ;  the  res- 
piration was  now  heard  equally  over  the  whole  right  side,  but 
only  in  a  slight  degree  ;f  it  was  also  perceptible  over  the  whole 
of  the  left  side,  except  below  the  sixth  rib.  The  patient  became 
somewhat  relieved  after  this  period,  but  he  finally  sunk  on  the 
12th  August. 

Dissection. — The  left  side  of  the  chest  was  found  one-third 
smaller  than  the  right,  and  the  intercostal  spaces  much  narrower. 
The  lung  on  this  side  was  intimately  united  to  the  pleura  of  the 
ribs,  in  its  whole  extent,  by  a  small  membrane  one  line  thick  in  ' 
its  superior  part,  and  two  lines  in  its.inferior  part.  It  was  white,  • 
of  a  consistence  almost  equal  to  that  of  flbro-cartilage,  and  of  a 
texture  somewhat  similar ;  as  fibres,  both  longitudinal  and  trans- 
verse, were  very  visible  in  it,  especially  at  its  inferior  part.  In 
several  places  this  false  membrane  was  united  to  the  pleura  by 
means  of  cellular  substance  containing  serum  ;  in  other  places, 
these  two  were  closely  united,  yet  still  very  distinguishable  from 
each  other.  The  lung  was  flattened  upon  the  mediastinum. 
Its  substance  was  still  somewhat  crepitous,  but  flaccid  and  in- 
jected with  serum.  It  contained  many  tubercles,  for  the  most 
part  miliary.  The  right  lung  adhered  to  the  costal  pleura  by 
meane  of  a  soft  false  membrane,  which  exhibited  reddish  vascular 

*  This  return  of  respiration  in  parts  where  it  had  previously  been  impercepti- 
ble, is  analogous  to  the  establishment  of  puerile  respiration  in  a  sound  lung  up- 
on the  other  becoming  diseased ;  and  seems  to  me  confirmatory  of  what  I  had 
occasion  to  state  above  (page  440,  et  seq.)  respecting  the  active  dilatation  of  the 
lungs. — Author. 

t  These  signs  compared  with  those  of  the  day  before,  indicated  that  the  effu- 
sion was  small  in  quantity,  and  diffused  uniformly  over  the  surface  of  the  lungs. 
At  this  time  I  was  very  imperfectly  acquainted  with  JEgophony.— Author. 


CONTRACTION    OF    THE    CHEST. 


495 


points  on  its  surface.  A  still  thicker  layer  of  the  same  kind 
invested  the  diaphragm  and  adjoining  lung.  There  was  about 
a  glassful  of  reddish  serosity  in  the  cavity  of  the  pleura.  The 
tissue  of  the  lung  was  crepitous,  containing  a  considerable  quan- 
tity of  serosity,  and  also  several  miliary  tubercles.  The  whole 
of  the  intestines  were  united  together  in  one  mass,  and  to  the 
peritoneum,  by  well-organized  cellular  substance,  intermixed  with 
small  tuberculous  masses.  The  mucous  membrane  of  the  ccecum 
and  colon  were  ulcerated. 

Case   XXXIII.     Hemorrhagic  pleurisy.     Incipient  contrac- 
tion of  the   chest. — A   man  aged   sixty-six,   in   October,  1817, 
caught  a  severe  cold,  and  became  affected  with  a  dry  cough,  and 
loss   of  appetite.     In   the    following  January,  haemorrhage  from 
the  lungs,  and  pains  of  the  chest,  were  added  to  his  complaints. 
He  got  worse,  with  a  good  deal  of  irregular  fever,  and  great 
dyspnoea  on  motion,  and  came  into  the  Necker  Hospital  on  the 
12th  of  March.     At  this  time  the  face  was  flushed,  the  tongue 
white,  and  the  pulse  hard  and  frequent ;  there  was  much  cough, 
with  an  expectoration  of  yellowish,   semi-transparent,   and  some- 
what frothy  sputa,  so  viscid  as  to  adhere  to  the  bottom  of  the 
vessel  when  reversed.     On  the  left  side,  percussion  elicited  every 
where  the  natural  sound,  and  the  stethoscope  indicated  the  respi- 
ration to  be  good.     On  the  right  side,  percussion  did  not  give  a 
very  good  sound  anteriorly,  and  gave  an  imperfect  sound  pos- 
teriorly ;  and  the  respiration  was  inaudible  over  the  lower  half 
of  the  back  and   side.      The  following  was  the  diagnosis  re- 
corded : — Chronic  pleurisy  on  the  right  side,  with  a  slight  acute 
pneumonia;  tubercles.*     The  patient  was  bled  and  leeched  with 
relief.     On  the  3rd  of  April  he  felt  pretty  well ;  there  was  little 
fever;  and  the  chest  sounded  nearly  equally  well  under  both  cla- 
vicles :  the  respiration,  however,  was  still  weaker  under  the  right, 
and  was  not  at  all  perceptible  over  the  remainder  of  this  side. — 
During  the  following  fortnight,  the  patient  oontinued  to  improve : 
he  always  lay  on  the  sound  side.    On  the  22nd,  the  chest  sounded 
worse  on  the  right  back,  but  much  better  on  the  upper  parts  be- 
fore.    The   respiration,  however,  was  in    these  very  indistinct, 
and  was  not  at  all  audible  below  the  second  rib ;  in  the  axilla,  it 
was  accompanied  by  a  slight  rhonchus  posteriorly ;  it  was  per- 
ceptible in  a  slight  degree,  over  a  space  three  fingers  in  width, 
along   the  spine,  but  nowhere  else  on   this  side.     During  the 
month  of  May,  the  patient  became  anasarcous,  pale,  and  ema- 
ciated.    However,  the   sound  improved  over  the  upper  part  of 
the  right  side  before,  and  the  sphere  of  the  respiration  was  ex- 

*  The  pneumonia  was  indicated  by  the  exploration.  I  do  not  know  what 
led  me  to  suspect  the  existence  of  tubercles  :  probably  the  progress  of  the  dis- 
ease at  its  commencement. — Author. 


496  CONTRACTION    OF    THE    CHEST. 

tended  ;  it  being  now  perceptible,  in  a  slight  degree,  over  the 
cartilages  of  the  false  ribs'.  On  the  6th  of  June  it  was  observed 
that  the  intercostal  spaces  on  the  right  side  were  becoming 
smaller,  and  that  the  chest  seemed  to  be  contracting  on  this  side  ; 
and  on  the  18th  the  contraction  was  quite  obvious.  The  patient 
died  on  the  28th. 

Dissection  twenty-eight  hours  after  death. — On  examining  the 
chest  it  was  found  that  the  diameter  of  the  right  side,  both 
laterally  and  from  before  backwards,  was  less  by  an  inch  than 
that  of  the  left ;  and  the  intercostal  spaces  were  narrower.  The 
left  lung  was  of  the  natural  size,  had  no  adherence  to  the  pleura, 
and  was  crepitous  throughout.  It  was  gorged  with  blood,  es- 
pecially on  the  posterior  part.  It  contained  some  tubercles  in 
the  early  stages.  The  left  lung  was  one-third  less  than  the  right, 
and  adhered  intimately  to  the  costal  pleura  by  its  whole  upper 
lobe  as  low  down  as  the  second  and  third  ribs.  This  adhesion 
was  effected  by  a  well-organized  cellular  tissue,  evidently  of  an- 
cient date.  The  remaining  pleura  of  the  lungs  and  ribs,  in 
the  whole  of  the  lower  part  of  the  lung  and  the  anterior  portion 
corresponding  with  the  false  ribs,  was  also  closely  united  ;  but 
this  adhesion,  which  was  evidently  of  recent  date,  was  effected  by 
means  of  a  concrete  albuminous  layer,  three  lines  in  thinkness, 
of  a  yellow  color  and  opaque,  and  partially  tinged  with  blood. 
This  membraniform  layer  could  be  removed  in  plates,  which 
were  of  greater  firmness  the  nearer  they  approached  the  pleura, 
on  either  side,  especially  the  pleura  pulmonalis, — on  which  they 
had  a  degree  of  consistence  nearly  equal  to  that  of  the  fibro-car- 
tilages.  On  the  contrary,  the  centrical  layers  were  hardly  of  a 
tenacity  double  that  of  boiled  white  of  egg.  At  the  point  of 
junction  of  the  ribs  with  their  cartilages,  and  on  the  anterior  and 
exterior  parts  of  the  lung,  this  albuminous  stratum  was  divided 
into  two  layers,  one  of  which  invested  all  that  portion  of  the  lung 
remaining  unattached' to  the  side,  and  the  other  the  corresponding 
portion  of  the  pleura;  and  these  two  afterwards  united  so  as  to 
form  a  shut  sac  or  pouch.  The  inner .  surface  of  this  sac  was 
nearly  every  where  of  a  bright  red  color,  which  seemed  as  if 
applied  with  a  pencil,  and  amid  which  no  traces  of  vessels  could 
be  distinguished.  This  red  color  did  not  at  all  enter  into  the 
substance  of  the  albuminous  stratum,  which  was,  throughout,  of 
a  yellowish-white  color,  and  slightly  semi-transparent,  becoming 
more  white  and  opaque  as  it  approached  the  pleura.  This  sac 
contained  about  two  glassfuls  of  a  bloody  but  limpid  serum, 
which  compressed,  at  this  part,  the  lung  towards  the  mediastinum, 
leaving  a  space  between  it  and  the  ribs  of  an  inch  and  a  half  at 
its  greatest  width.  Eight  or  ten  pseudo-membranous  bands 
crossed  this  cavity,  being  attached,  at  each  end,  to  the  pleuritic 


CONTRACTION    OF    THE    CHEST.  497 

layers.  These  were  softer  and  more  fragile  than  old  cellular  ad- 
hesions ;  they  were .  very  thin,  diaphanous,  and  colorless,  to- 
wards their  middle,  but  at  their  extremities  they  assumed  greater 
firmness,  and  also  the  opacity  and  color  of  the  layers  to  which 
they  were  attached.  In  the  top  of  this  lung  there  was  an  exter- 
nal depression,  corresponding  with  a  fibro-cartilaginous  substance 
internally,  such  as  was  formerly  described  under  phthisis  pulmo- 
nalis  and  which  was  proved  to  be  a  true  cicatrization  of  a  tuber- 
culous cavity.  In  its  interior  parts  the  lung  was  flaccid,  not 
crepitous,  dry,  and  resembling  muscular  flesh,  over  the  lower 
three-fourths ;  while,  in  the  superior  fourth,  it  was  crepitous, 
rose-colored,  and  contained  a  little  frothy  serum.  In  the  upper 
portion  there  were  many  immature  tubercles.  The  pleura,  in 
the  parts  corresponding  to  the  false  membranes,  was  much  redder 
than  natural.  The  heart  was  sound.  The  cavity  of  the  perito- 
neum contained  about  four  pints  of  a  reddish  serosity,  partially 
limpid.  The  whole  of  the  peritoneum,  as  well  on  the  abdominal 
parietes,  as  on  the  mesentery  and  intestines,  was  studded  with 
innumerable  small,  grey,  semi-transparent  tubercles.  Upon  the 
mesentery  and  bowels  these  were  quite  transparent,  and  of  the 
size  of  millet-seed  ;  on  the  abdominal  parietes  they  were  flatter, 
greyer,  and  less  diaphanous.  The  peritoneum  was,  moreover, 
marked  in  different  places,  by  red  punctuated  spots,  which  were 
either  of  a  bright  red,  or  almost  black.  In  these  points,  on 
scraping  with  the  scalpel,  a  small  quantity  of  a  semi-transparent 
exudation,  of  a  grey  color,  and  mixed  with  dots  of  blood,  could 
be  detached.  This  matter  was  very  like  paste,  only  a  little  firmer. 
It  was  so  thin  as  only  to  be  discovered  by  scraping:  after  its  re- 
moval the  peritoneum  appeared  somewhat  less  red.  The  tuber- 
cles seemed  to  be  so  intimately  connected  with  the  peritoneum, 
as  not  to  be  detached  by  scraping :  this  membrane  was  not  sen- 
sibly thickened. 

Case  XXXIV. — Hemorrhagic  pleurisy  of  the  left  side,  with 
ascites  and  organic  diseases  of  the  liver. — A  man  had  had  an 
attack  in  the  chest  when  twenty-four  years  old  ;  but  afterwards 
enjoyed  very  good  health,  until  the  summer  of  1818,  when  he 
became  affected  with  slight  anasarca ;  and  this  was  followed,  in 
December,  by  cough.  He  came  into  the  hospital  on  the  13th  of 
the  following  March,  in  his  forty-seventh  year.  At  this  time  he 
presented  the  following  symptoms  :  moderate  oedema  of  the  feet 
and  legs,  slight  expectoration,  partly  White  and  frothy,  partly 
yellow  and  opaque.  The  chest  sounded  equally  well  throughout, 
and  the  respiration  (on  a  hasty  examination)  seemed  scarcely  per- 
ceptible on  both  sides.  17th.  The  chest,  on  a  more  careful  ex- 
amination, gave  the  following  results  :  the  left  side  behind  seems 
to  sound  worse  than  the  right, — both  sides  laterally  yield  a  very 
63 


498  CONTRACTION  OF  THE  CHEST. 

dull  sound, — the  anterior-superior  parts  sound  better.  The  res- 
piration is  very  distinct  over  the  whole  of  the  right  side  ;  on  the 
left,  on  the  contrary,  it  is  but  very  little  perceptible  below  the 
clavicle  and  at  the  roots  of  the  lungs,  and  not  at  all  audible  over 
the  remaining  parts  of  this  side.  The  following  diagnosis  was 
given  :  Imperfectly  cured  pleurisy  of  the  left  side,  co-existing 
perhaps  with  tubercles.  In  the  end  of  March  the  oedema,  which 
had  been  lessened,  now  became  greater,  the  belly  swelled,  and 
the  appetite  diminished.  At  this  time,  the  respiration  on  the  right 
side  was  accompanied  with  a  strong  and  sonorous  rhonchus,  on 
the  lateral  parts  anteriorly,  and  was  scarcely  perceptible  behind, 
and  over  the  whole  of  the  left  side.  Percussion  elicited  a  very 
imperfect  sound  from  the  whole  of  the  left  side,  except  on  the 
anterior-superior  part ;  but  the  whole  right  side  sounded  well. 
vEgophony  existed  very  distinctly  over  the  supra-spinous  fossa  of 
the  left  scapula.  The  voice  having  the  bleating  character  strongly 
marked,  seemed  to  come  through  the  tube  of  the  stethoscope, 
and  was  more  acute  than  the  natural  voice  of  the  patient.  In 
consequence,  I  modified  the  diagnosis  as  follows  :  chronic  pleurisy 
of  the  left  side,  with  pulmonary  catarrh.  From*  the  30th  March 
,  to  the  15th  April,  the  repeated  examination  of  the  chest  showed 
that  on  the  right  side,  the  sonorous  rhonchus  had  in  a  great 
measure  ceased,  and  that  the  respiration  was  louder  than  natural 
(puerile) ;  whilst,  on  the  left  side,  the  respiration  seemed  extinct, 
except  along  the  inner  border  of  the  scapula  and  immediately 
below  the  clavicle,  in  which  places  it  was  just  barely  perceptible. 
The  point  just  mentioned  (under  the  clavicle)  was  the  only  one 
on  this  side  which  yielded  any  sound  on  percussion.  During  the 
first  days  of  April,  aegophony  was  still  audible  along  the  inner 
margin  of  the  scapula,  but  the  voice  had  assumed  a  grave  key, 
and  was  heard  better  with  the  stopper  of  the  tube  removed  ;  it 
disappeared  entirely  on  the  5th.  The  natural  respiration  was 
short  and  somewhat  noisy.  The  patient  lay  usually  on  the  left 
side,  sometimes  on  the  back,  but  he  could  not  lie  on  the  right  side. 
About  the  middle  of  the  month,  the  respiration  seemed  more 
easy,  and  the  patient  could  lie  two  or  three  hours  on  the  right 
side ;  but  the  anasarca  increased,  and  hectic  fever  came  on. 
From  the  7th  to  the  14th  of  May,  the  resonance  of  the  chest  be- 
came clearer  on  the  anterior  and  upper  part  of  the  left  side,  and 
the  respiration  became  more  audible  in  the  same  points  ;  it  was 
also  somewhat  perceptible  below  the  axiHa,  and  was  here  accom- 
panied by  a  pretty  strong  mucous  rhonchus :  in  every  other  part 
of  this  side  both  the  resonance  and  the  respiration  were  wanting. 
He  died  on  the  17th. 

Dissection  thirty  hours   after  death. — The  thorax  appeared 
larger  on    the  upper  part,  and  smaller  on   the  lower  part  of  the 


CONTRACTION    OF    THE    CHEST. 


499 


left  side,  than  the  right.  The  left  cavity  of  the  pleura  contained 
at  least  two  pints  of  a  very  bloody  serum,  and  the  lung,  on  this 
side,  was  thereby  compressed  towards  the  mediastinum  and  upper 
part  of  the  chest.  A  large  vacant  space  was  thus  left  between 
the  lung  and  "ribs,  which  space  gradually  lessened  from  below 
upwards,  but  was  still  an  inch  in  diameter  as  high  as  the  middle 
of  the  scapula.  This  space  was  lined  by  a  false  membrane,  the 
internal  surface  of  which  was  tinged  uniformly  of  a  bright  scarlet 
color,  and  was  crossed  in  every  direction  by  fine  fibrous  bands 
of  the  same  kind.  In  many  parts  of  these  false  membranes  there 
were  clots  and  thin  layers  of  a  dark-colored  blood.  The  under 
layer  of  membrane  which  adhered  to  the  pleura  was  of  a  greyish 
yellow  color,  homogeneous,  and  of  a  structure  and  consistence 
resembling  the  fibro-cartilages.  It  contained  within  it  an  immense 
multitude  of  greyish  tubercles,  of  the  size  from  that  of  a  millet- 
seed  to  a  grain  of  corn,  or  even  a  pea.  These  were  of  a  firmer 
consistence  than  the  including  membrane  ;  and  they  formed  more 
than  one  half  of  its  whole  substance.  The  left  lung,  compressed 
as  already  mentioned,  was  reduced  to  nearly  one-fourth  of  its 
natural  size  ;  it  was  adhering  to  the  pleura  by  its  inner  side,  its 
summit,  and  by  two-thirds  of  its  exterior  and  superior  aspect. 
Detached  from  the  false  membrane  it  was  sound,  only  com- 
pressed, flaccid,  and  void  of  air  except  in  its  lower  lobe.  The 
blood-vessels  and  smaller  bronchial  tubes  were  flattened  and 
much  contracted.  The  right  lung  adhered  to  the  ribs  only  in  a 
few  points,  and  by  old  and  perfectly  organized  attachments.  It 
was  gorged  with  a  great  quantity  of  frothy  serum  which  flowed 
out  on  its  being  cut.  The  cavity  of  the  peritoneum  contained 
five  or  six  pints  of  serum.  The  liver  was  reduced  to  one-third 
of  its  usual  size,  and  when  cut  into  was  found  to  be  entirely 
composed  of  a  multitude  of  small  grains  of  a  round  or  ovoid 
shape,  and  varying  in  size  from  that  of  a  millet-seed  to  a  hemp- 
seed.* 

*  Since  the  publication  of  the  first  edition  of  this  work,  which  contained  the 
earliest  history  of  this  singular  termination  of  pleurisy,  contraction  of  the  chest 
has  been  noticed  by  many  authors  as  well  in  this  country  as  on  the  continent. 
I  stated  in  a  former  note  my  opinion  that  this  deformity  is  not  the  consequence 
of  the  hemorrhagic  pleurisy  exclusively;  and  I  may  here  add,  that  the  fact  of 
its  occurrence  after  traumatic  pleurisy,  and  after  the  operation  of  empyema,  is 
sufficient  proof  of  the  correctness  of  that  opinion.  Baron  Larrey  in  the  Journ. 
Compliment,  des  Sc.  Med.  for  May,  1820,  details  several  interesting  cases  of 
chronic  pleurisy  and  empyema  resulting  from  wounds,  in  some  of  which,  tJie 
contraction  was  strongly  marked.  In  Dr.  Hasting's  valuable  paper  on  Empy- 
ema in  the  first  number  of  the  Ed.  Journ.  of  Med.  Science,  p.  17,  several  cases 
of  the  same  kind,  following  the  operation  of  empyema,  are  mentioned;  and  a 
like  contraction  took  place  after  a  successful  operation  in  empyema,  in  the  very 
interesting  case  recorded  by  Mr.  Jowett  (Med.  Chir.  Rev.  for  July,  1826,  p.  267.) 
It  may  indeed  be  said,  and  perhaps  truly,  that  the  morbid  alteration  of  structure 
within  the  chest  is  not  the  same  in  the  two  classes  of  cases.     In  my  work  en- 


500  PARTIAL    PLEURISY. 


Sect.  VII. — Of  circumscribed  or  partial  Pleurisy. 

It  occasionally  happens,  particularly  in  chronic  pleurisy,  that 
the  effused  fluid  is  confined  to  a  partial  space  of  small  extent, 
owing  to  the  obliteration  of  the  remainder  of  the  cavity  of  the 
pleura  by  former  adhesion.  I  formerly  stated,  that  inflammation 
is  excited  with  much  more  difficulty,  and  occurs  more  rarely,  in  a 
pleura,  the  different  parts  of  which  are  united  by  old  cellular 
adhesions,  than  in  a  perfectly  sound  membrane.  It  is  no  doubt 
from  the  same  cause,  that,  in  the  event  of  a  fresh  inflammation 
attacking  a  portion  of  the  pleura  that  had  remained  unaffected 
in  a  previous  seizure,  the  phlogosis  and  its  products,  coagulable 
lymph  and  serous  effusion,  are  found  to  be  exactly  circumscribed 
by  the  old  adhesions.  These  circumscribed  pleurisies  may  occur 
in  any  part  of  the  surface  of  the  lungs,  but  are  observed  in  the 
three  following  situations  chiefly  :  1st.  the  fissures  between  the 
different  lobes  ;  2nd.  the  space  between  the  base  of  the  lungs  and 
the  diaphragm  ;  and  3rd.  the  posterior-inferior  and  lateral  part 
of  the .  cavity  of  the  pleura.  In  these  cases  the  effused  fluid, 
which  is  commonly  puriform,  is  enclosed  in  a  false  membrane 
which  lines  very  exactly  the  surrounding  parts.  When  seated 
in  the  fissures  between  the  lobes,  the  edges  of  these  are  found 
closely  adherent  by  means  of  a  very  short  cellular  substance,  of 
a  formation  evidently  of  more  ancient  date  than  the  present  dis- 
ease, while  the  opposing  surfaces  of  the  lobes  themselves  are 
separated  by  the  interposed  effusion.  Bayle  was  the  first  who 
described  this  species  of  partial  pleurisy,  which  an  inattentive 
observer  might  easily  mistake  for  an  abscess  of  the  lung.  This 
species  is  rare ;  a  thing  which  seems  rather  singular,  when  we 
consider  how  often  we  find  the  edges  of  these  interlobular  fissures 

titled  "  Original  Cases,"  two  instances  of  contracted  chest  are  given  (Cases  xxiv. 
xxv.  p.  237.  245.)  The  event  of  the  first  case  is  given  in  that  publication  ;  that 
of  the  second  I  shall  here  state.  After  the  date  of  the  last  report  in  May,  1824, 
1  saw  the  poor  man  occasionally  during  the  remainder  of  that  year  and  part  of 
the  succeeding,  when  he  continued  much  in  the  same  state.  I  then  lost  sight 
of  him.  and  only  learned  lately  that  he  died  in  the  end  of  1826,  after  having 
long  labored  under  symptoms  which  leave  no  room  to  doubt  that  perforation  of 
the  lung  and  consequent  communication  between  the  bronchi  and  pleuritic  effu- 
sion had  taken  place.  In  another  case,  of  which  a  brief  notice  is  given  in  my 
little  work,  (the  Case  of  Mr.  U.  p.  225.  Case  xxii.)  contraction  of  the  chest  has 
taken  place  in  a  very  marked  degree,  and  has  happilv  been  the  medium  of  a 
complete  cure.  Mr.  U.  is  now  (Aug.  18:14)  in  perfect  health,  but  with  the  alte- 
ration of  shape  so  beautifully  detailed  in  the  preceding  section.  In  Mr.  Jowett's 
case,  the  contraction  of  the  chest  appears  to  have  been  partially  removed  in  the 
progress  of  rlif-  ,-u,-c.  yhja  c.u.t  js  sufficient  proof  that  the  contraction,  in  this 
instance  was  not  effected  by  means  of  the  tibro-cartilagiiioiis  membranes.  It  is 
necessary  to  distinguish  this  species  of  contraction  from  ihat  congenital  variety 
recently  described  by  M.  Dupuytren,  under  the  name  of  Lateral  depression  of 
the  thoracic  ponetes.     See  Repertoire  Gin.  d'Jnat.  1828.—  Transl. 


PARTI  AT    PLEURISY. 


iOl 


adherent  in  cases  of  pneumonia  attended  by  a  slight  pleurisy ; 
even  when  the  remaining  surfaces  of  these  fissures  are  quite  free 
from  adhesion.  In  such  cases  it  would  seem  that  the  resolution 
of  the  pneumonia  leaves  these  fissures  converted  into  a  sort  of 
sac,  which  will  occasion  the  circumscribed  effusion  we  have  been 
describing,  in  the  event  of  that  part  of  the  pleura  being  aftei  wards 
attacked  by  inflammation.  In  order  to  effect  this  circumscrip- 
tion of  the  fluid,  it  is  by  no  means  necessary  that  the  adhesions 
on  the  edges  of  the  fissures  shall  be  so  numerous  or  close  as 
actually  to  close  the  passage  of  a  liquid  into  the  common  sac  of 
the  pleura ;  if  they  are  only  pretty  numerous,  although  with 
some  intervals  between  them,  they  suffice  to  limit  the  progress  of 
the  inflammation.  And  the  same  thing  occurs,  as  formerly  men- 
tioned, in  other  instances  of  circumscribed  pleurisy  ;  the  albu- 
minous effusion  of  the  recent  inflammation,  never  penetrating 
more  than  a  few  lines  into  the  meshes  of  the  old  adhesions,  how- 
ever loose  and  unconnected  these  may  be  with  regard  to  each 
other.  The  effusion  between  the  base  of  the  lung  and  the  dia- 
phragm, is  usually  circumscribed  by  the  borders  of  the  lung 
agglutinated  by  some  previous  inflammation.  Occasionally,  how- 
ever, the  extravasation  is  confined  to  a  portion  of  the  base,  the 
remainder  being  adherent.*  The  circumscribed  effusions  on  the 
lateral  and  posterior-inferior  part  of  the  chest,  are  more  common 
than  the  others.  Sometimes  I  have  met  with  partial  effusions  of 
this  sort,  near  the  summit  of  a  lung,  adherent  in  every  other 
point,  consisting  only  of  one  or  two  spoonsful ;  and  I  have  ob- 
served similar  collections  between  the  inner  edge  of  the  lung  and 

*  This  variety  of  partial  pleurisy,  and  which  constitutes  what  is  sometimes 
termed  Diaphragmitis ,  is  by  no  means  uncommon  :  it  often  presents  such  a 
group  of  symptoms  as  entitle  it  to  particular  notice.  The  following  description 
of  it  by  Dr.  Law  (Cyc.  qJ  Prart.  Med.  vol.  iii.  p.  392)  accurately  represents  the 
symptoms  in  many  cases  of  this  affection.  "  Its  characteristic  features  are,  in 
addition  to  the  ordinary  constitutional  symptoms  of  acute  pleurisy,  pain  more 
or  less  acute  of  the  cartilaginous  border  of  the  false  ribs,  extending  into  the 
hypochondria,  and  even  the  flanks;  complete  immobility  of  the  dfaphragm  in 
inspiration,  which  is  performed  by  the  elevation  of  the  ribs;  orthopnosa  with 
an  inclination  of  the  body  forwards;  an  inexpressible  anxiety  of  countenance, 
marked  by  a  sudden  change  of  features;  the  respiration  more  hurried  and  jerky 
than  in  the  ordinary  pleurisy  ;  the  voice  low  and  interrupted;  a  frequent  desire 
to  cough,  but  an  obvious  dread  of  it  from  the  pain  which  it  causes.  The  intel- 
lect is  at  first  free,  but  when   the   case  is   aggravated,  and  the  constitutional 

symptoms  run  high,  delirium  comes  on These  may  be  regarded  as  the 

most  constant  and  unequivocal  signs  of  diaphragmatic  pleurisy ;  others  are 
occasionally  present,  viz.  hiccup,  nausea,  vomiting,  jaundice,  &c.  It  was  the 
presence  of  jaundice  that  led  Valsalva  to  regard  the  accidental  complication  as 
the  original  disease ;  a  mistake  which  might  naturally  occur  if,  as  happens  in 
many  cases,  the  features  of  the  preceding  pleurisy  had  not  been  strongly  marked. 
The  risus  sardunicus,  to  which  the  ancients  attributed  so  much  importance  as 
characteristic  of  this  modification  of  disease,  has  not  been  found  constant  by 
modern  observers." — Transl. 


50*2  .  PARTIAL    PLEURISY. 

mediastinum.     Anclral  has  recorded  a  more  extensive  example  of 
this  variety.* 

Certain  cases  of  circumscribed  pleurisy  are  formed  in  another 
manner  and  independently  of  any  preceding  adhesions :  in  some 
instances  of  very  slight  pleurisy,  particularly  such  as  accompany 
pneumonia,  it  frequently  happens  that  the  pseudo-membranous 
exudation  is  confined  to  the  sharp  edges  ot  the  lungs,  or,  at  least, 
is  vastly  thicker  on  these  parts  than  elsewhere,  thereby  forming  a 
sort  of  border,  of  a  yellowish-white  color,  and  more  or  less 
opaque.  Should  it  happen  that  these  prominent  borders  adhere 
to  the  corresponding  parts  of  the  costal  pleura,  and  any  renewal 
of  the  inflammation  takes  place,  it  will  be  found  that  the  fresh 
inflammation  and  its  accompanying  effusion,  are  confined  within 
these  boundaries.  Some  acute  circumscribed  pleurisies  of  this 
sort  I  have  seen  both  on  the  diaphragm  and  in  the  interlobular 
fissures.  Andral  relates  three  cases  of  diaphragmatic  pleurisy, 
which  probably  were  of  the  kind  just  mentioned  ;f  although  the 
scantiness  of  the  details  renders  this  somewhat  doubtful.  A 
fourth  case  of  his,  produced  by  the  rupture  of  a  gangrenous 
cavity  on  the  base  of  the  lung,  was  certainly  of  this  kind. 

Wherever  these  partial  pleuritic  collections  are  situated,  If  at 
all  abundant,  they  strongly  depress  the  pulmonary  substance, 
(being  unable  to  extend  themselves  in  any  other  direction,)  and 
form  a  sort  of  cavity  within  it,  which,  at  first  sight,  one  would 
be  disposed  to  consider  as  formed  by  an  actual  loss  of  continuity 
of  the  lung :  however,  upon  removing  the  pus  and  the  false 
membrane,  we  find  the  pulmonary  substance  merely  compressed 
and  quite  sound.  Partial  pleurisies  of  the  first  kind,  are  less 
severe  in'  themselves,  because  they  are  almost  always  complica- 
tions of  much  more  dangerous  diseases,  and  particularly  phthisis 
pulmonalis.  Those  of  the  second  kind,  on  the  other  hand,  are 
not  of  much  consequence  in  any  point  of  view  ;  and  this  is  suffi- 
ciently proved  by  the  fact,  that  it  is  extremely  rare  to  meet  with 
such  actually  existing  in  the  dead  body,  while  it  is  very  common 
to  find  the  traces  of  their  cure.  • 

Signs  and  symptoms. — These  circumscribed  and  partial  effu- 
sions may  be  readily  recognized  by  absence  of  respiration  and 
resonance,  and  sometimes  even  by  aegophony,  over  their  site, 
when  they  are  of  a  certain  extent.  I  have  perceived  aegophony 
in  cases  in  which  the  effusion  did  not  exceed  a  few  ounces. 
Andral  met  with  it  also  in  the  case  of  a  more  considerable  effu- 
sion confined  between  the  diaphragm,  the  basis  of  the  lung,  and 
the  mediastinum.  (CI.  Med.  obs.  xxxii.)  However,  when  aego- 
phony is  wanting,  and  if  a  stitch  did  not  exist  at  the  commence- 

*  CI.  Med.  t.  ii.  obs.  xxiv.  t  CI.  Med.  obs.  xix.  xxxii. 


LATENT    PLEURISY. 


503 


ment,  it  may  be  very  difficult  to  distinguish  a  partial  pleurisy 
from  a  large  tumor  in  the  substance  of  the  lungs. 

Sect.  VIII. — Of  latent  Pleurisy. 

Several  physicians  of  the  last  century,  and  particularly  Stoll, 
had  remarked,  that  in  many  cases  of  pleurisy,  the  stitch,  which 
commonly  attracts  attention  to  the  character  of  the  disease,  is 
altogether  wanting ;  and  that  the  insidious  mildness  of  the  whole 
symptoms,  in  the  early  stage,  is  such  as  not  even  to  excite  any 
suspicion  of  a  severe  affection.  Notwithstanding  these  hints, 
however,  it  cannot  be  denied,  that,  previously  to  the  use  of  per- 
cussion and  auscultation,  many  pleurisies  which  in  the  first  in- 
stance were  taken  for  trifling  affections,  in  a  later  stage  were  re- 
garded as  consumptions,  especially  by  the  physicians  who  were 
not  accustomed  to  seek  in  dissection  for  the  tests  of  the  truth  of 
their  diagnosis.  It  occurred  to  myself  not  many  years  since, 
to  prescribe  the  operation  of  empyema  in  the  case  of  a  young 
man  who  had  been  put  under  my  care  as  a  consumptive  subject 
in  extremis,  but  in  whose  lungs,  when  examined  after  death,  there 
did  not  exist  a  single  tubercle.*  Indeed,  the  subject  of  latent 
pleurisy  must  be  rendered  much  less  difficult,  by  the  details  al- 
ready given  in  this  chapter ;  insomuch  that  I  consider  myself 
justified  in  asserting,  that,  to  the  physician  who  employs  percus- 
sion and  auscultation,  these  cases  will  be  reduced  to  a  very  small 
number,  and,  in  fact,  will  consist  only  of  such  as  it  is  of  little 
practical  importance  to  distinguish.  These  will  be  the  following  : 
— 1.  a  few  partial  pleurisies  of  small  extent; — 2.  those  which 
supervene  during  the  last  hours  of  most  diseases,  particularly 
phthisis  and  severe  continued  fevers,  and  for  the  most  part  in 
winter;  and  3.  the  dry  pleurisies,  or  such  as  are  almost  unaccom- 
panied by  effusion  :  all  of  which  belong  to  the  second  class  of 
cases,  or  to  pleuro-pneumonia,  with  the  predominance  of  pneu- 
monia. These  cases,  moreover,  are  only  recognized  with  dif- 
ficulty, because  of  our  unwillingness  to  disturb  uselessly,  the  last 

*  In  this  case  the  operation,  in  the  first  instance,  proved  very  successful,  inso- 
much that  the  patient,  at  the  end  of  a  fortnight,  was  able  to  walk  abroad  ;  and 
although  the  progress  of  the  cure  was  subsequently  checked  by  frequent  excesses 
at  table,  the  flesh  and  strength,  nevertheless,  returned  completely.  At  the  end 
of  the  eighth  month,  there  existed  only  a  small  fistula  into  which  one  or  two 
spoonsful,  at  most,  could  be  injected.  The  patient  now  thought  it  incumbent 
on  him  to  celebrate  his  recovery,  and  terminated  his  fete  by  being  carried  from 
the  table  dead-drunk,  together  with  the  whole  of  his  guests.  This  debauch 
was  followed  by  a  severe  fever,  accompanied  by  delirium,  during  which  he 
would  not  permit  the  wound  to  be  dressed;  and  when  it  was  examined,  at  the 
end  of  a  fortnight,  the  pleura  was  found  detached,  and  the  cavity  so  enlarged 
as  to  be  capable  of  receiving  a  pint  of  injection.  From  this  time  the  suppura- 
tion assumed  a  bad  character,  emaciation  returned,  and  the  man  died,  worn  out, 
after  a  few  months. — Author. 


504  TREATMENT    OF    PLEURISY. 

moments  of  our  patients  ;  more  particularly  in  exploring  the 
posterior-inferior  parts  of  the  chest,  where  the  effusion  first  shows 
itself.* 

Sect.  IX. — Treatment  of  Pleurisy. 

In  acute  pleurisy,  when  the  patient  is  strong  and  plethoric, 
venesection  has  been  uniformly  recommended  by  the  best  prac- 
titioners of  all  ages.f  Should  the  pain  and  fever  not  yield  to  the 
first  or  second  bleeding,  however,  it  will  be  better  practice  in  this, 
as  in  all  other  inflammations  of  serous  membranes,  to  follow  up 
the  cure  by  local  bleedings.  These,  generally  speaking,  must  be 
continued  until  the  pain  and  fever  go  off;  and  must  be  repeated 
should  they  afterwards  return.  Cupping,  in  these  cases  is,  in 
my  opinion,  preferable  to  leeches,  and  for  many  reasons :  by  the 
former  method  we  can  take  away  the  exact  quantity  of  blood 
which  we  want,  while  the  operation  is  at  the  same  time  much 
quicker  and  less  painful.  Leeches  are  often  very  tedious  and 
painful  in  their  action ;  sometimes  they  scarcely  fill  themselves 
with  blood,  and  at  other  times  their  punctures  will  continue 
bleeding  for  twenty-four  hours,  and  can  only  be  closed  by  the 
cautery.  I  am  acquainted  with  recent  (and  even  fatal)  examples 
of  this  accident,  which  has  occurred  in  different  hospitals, — and 
which  might  have  been  safely  left  to  nature.J     During  the  first 

*  Pleurisy  in  some  one  or  other  of  its  forms,  has  in  all  ages  attracted  the 
marked  attention  of  practitioners  :  on  this  account  its  literature  is  extremely 
extensive.  For  a  list  of  the  best  works  of  the  older  writers  on  the  subject,  I 
refer  the  reader  to  Dr.  Young's  Medical  Literature,  2nd  Ed.  p.  231.  In  these 
the  student  will  obtain  much  information  respecting  the  general  symptoms  and 
treatment  of  pleurisy  ;  and,  after  studying  the  real  pathology  of  the  disease  in 
our  author,  will  derive  much  practical  information  from  the  perusal  of  them. 
The  only  works,  however,  which,  in  a  pathological  point  of  view,  can  at  all 
bear  comparison  with  the  admirable  account  given  by  M.  Laennec  in  the  pres- 
ent chapter,  are  those  of  Broussais  and  Andral.  See  Pklegmasies  Chroniqucs, 
t.  i.  p.  220  :  Clinique  Midicale,  t.  ii.  p.  85.  Compared  with  these  works  it  is 
but  simple  justice  to  state,  that  all  our  English  writings  relative  to  the  pathology 
of  pleurisy  sink  into  insignificance.  The  earlier  authors  best  deserving  the 
student's  attention  on  the  subject  of  pleurisy  are  Stoll,  Morgagni,  Baglivi, 
Wendt,  Triller,  Hoffmann,  Huxham,  Cleghorn,  Frank,  <fec.  For  some  valuable 
remarks  on  the  chronic  form  of  the  disease,  I  refer  to  Dr.  Armstrong's  Treatise 
on  Scarlet  Fever,  p.  193  ;  to  Dr.  Abercrombie's  Essay  on  the  Pathology  of  Con- 
sumptive Diseases,  Edin.  Journ.  vol.  xvii.  p.  29;  and  to  Dr.  Hasting's  paper 
on  Empyema  already  noticed.  I  would  also  refer  the  reader  to  the  excellent 
articles  on  pleurisy  in  the  Diet,  de  Scienc.  Med.  t.  xliii.  p.  185,  by  Pinel  and 
Bricheteau;  the  Diet,  de  Mid.  t.  xvii.  p.  127,  by  Chomel  ;  and  The  Cyclopaedia 
of  Practical  Medicine,  by  Dr.  Law.  Of  these  the  essays  by  M.  Chomel  and  Dr. 
Law  may  be  recommended  to  the  student  as  admirable  epitomes  of  all  that  is 
known  respecting  the  pathology  of  this  disease.—  Transl. 

t  In  females,  near  the  period  of  the  catamenia,  the  blood  has  been  by  prefer- 
ence, and  properly,  taken  from  the  foot.— Author. 

X  The  danger  of  bleeding  from  leech-bites,  in  adults,  at  least,  is  here  much 
exaggerated.  One  of  the  many  practical  advantages  of  accurate  diagnosis  in 
pleurisy  and  pneumonia,  is  the  much  greater  benefit  derived  from  local  bleeding 


TREATMENT    OF    PLEURISY.  50 

days  of  the  disease,  the  patient  (unless  an  infant)  ought  to  receive 
no  food :  but  should  be  allowed  some  liquid  aliment,  at  least, 
after    three  or  four  days.     This  indulgence  is  the  surest  way  of 
escaping  these  interminable  convalescences,  occasioned  by  the 
passage  of  the  pleurisy  into  the  chronic  state.     Sydenham's  prac- 
tice of  getting  the  patient  out  of  bed,  if  he  can  bear  the  fatigue, 
and  of  keeping  him  up  several  hours  every  day,  is  very  proper ; 
and  has  frequently  appeared  to  me  to  contribute  powerfully  to- 
wards subduing  the  inflammation. — I   shall  say  nothing  in   this 
place  of  the  various  topical  applications,  hot  or  tepid,  dry  or 
moist,  which  were  formerly  cried  up  as  remedies  in  pleurisy. 
These  rarely  afford  any  relief ;  and  the  humid  applications,  in 
particular,  are  frequently  more  injurious  than  useful,  from  their 
becoming  cold.     When  the  stitch  does  not  yield  speedily  to  the 
general  and  local  bleedings,  some  practitioners  are  in  the  habit  of 
applying  a  blister  over  the  affected  part,  and  sometimes  of  keeping 
up  the  discharge  from  it.     I  have  sometimes  thought  that  the 
use  of  this  remedy,  in  a  very  early  stage  of  the  disease,  was  im- 
mediately followed  by  an  increase  of  the  pleuritic  effusion ;  and 
I  cannot  consider  the  practice  as  advisable,  until  after  the  com- 
plete cessation  of  the  pain  for  several  days,  and  unless  the  pro- 
gress of  the  absorption  is  slow,  and  the  disease  threatens  to  be- 
come chronic. — Tartar  emetic  in  large  doses,  is  commonly  very 
well  borne  by  patients  affected  with   pleurisy,  and  I  am  in  the 
habitual  employment  of  it  in  this  disease  as  well  as  in  pneumonia. 
It  contributes  powerfully,  in  most  cases  speedily,  to  subdue  the 
inflammatory  action,  and  does  away  with  the  necessity  of  ab- 
stracting so  large  a  quantity  of  blood.      However,  when   the 
violence  of  the  fever  and  the  stitch  have  ceased,  it  loses  almost 
all  its  power  over  the  disease  ;  or,  at  least,  it  retains  a  little  of 
its  admirable  efficacy,  even  although  the  system  bears  its  employ- 
ment very  well.     I  have  often  continued  its  administration  in  a 
dose  of  nine  grains   [per  diem]   for  several  successive  weeks, 
without  its  having  any  apparent  effect  in  accelerating  the  absorp- 
tion, and  indeed  without  any  effect  whatever  on  the  system.' 
For  these  reasons  I  now  restrict  its  employment  to  the  acute 
stage.     The  practice  of  giving  antimonials  in  pleurisy  has  been 
much  in  use.     Stoll  and  his  disciples  were  in  the  almost  constant 
habit  of  giving  the  tartar  emetic  in  the  commencement  of  the  dis- 
ease, to  produce  vomiting ;  and  a  vast  number  of  practitioners 
have  commended  the  use  of  kermes  in  frequently  repeated  doses.* 

in  the  former,  than  in  the  latter  disease.  I  believe  we  are  accustomed  in  this 
country  to  trust  too  much  to  general  and  too  little  to  local  bleeding  in  this  disease  : 
both  combined  in  moderation  are  greatly  preferable  to  either  in  excess. —  Transl. 
*  Tartar  emetic  in  large  doses  is  a  bad  remedy  in  pleurisy  :  its  benefit  is  very 
equivocal,  and  it  sometimes  gives  rise  to  serious  metastases.     In  one  case,  in  the 

64 


506  TREATMENT    OF    PLEURISY. 

To  the  means  above  mentioned  we  must  add  calomel  and  opi- 
um, so  strongly  recommended  by  Dr.  Robert  Hamilton,  to  whom 
we  owe  the  employment  of  the  same  remedies  in  hepatitis,  peri- 
tonitis, and,  indeed,  in  most  inflammatory  diseases.  I  have  my- 
self hardly  any  experience  of  this ,  practice  in  pleurisy  ;  as  I  gen- 
erally give  the  preference  to  mercurial  inunction  carried  to  a 
considerable  extent.  There  exists  no  doubt  in  my  mind,  that 
mercury  aids  the  resolution  of  inflammatory  diseases,  even  such 
as  are  chronic ;  and  I  have  proved  their  utility  in  promoting  ab- 
sorption subsequent  to  pleurisy.* 

The  means  now  enumerated,  suffice,  in  most  cases,  to  subdue 
the  inflammatory  action  and  fever,  and  even  to  establish  perfect 
convalescence.  But  it  must  be  admitted,  that,  in  this  as  in  most 
acute  diseases,  the  unaided  resources  of  nature  are  very  great ; 
and  that  the  greater  number  of  pleurisies,  if  left  entirely  to  them- 
selves, would  do  well.  This  much  is  certain,  that  a  cure  fre- 
quently takes  place,  when  the  treatment  amounts  to  almost 
nothing,  or  even  when  it  is  conducted  on  principles  opposed  both 
by  reason  and  experience.  It  is  even  now  by  no  means  un- 
common, particularly  in  country  places,  to  meet  with  persons 
who  attempt  the  cure  of  pleurisy  according  to  the  sudorific  plan 
of  Paracelsus  and  Vanhelmont,  that  is,  with  hot  wine  or  brandy 
and  aromatics,  such  as  pepper,  ginger,  cinnamon,  and  juniper  or 
coriander  berries :  the  dung  of  horses  or  sheep  infused  in  wine, 
&c.  And  yet  all  the  patients  of  these  sages  do  not  die  :  a  salu- 
tary crisis  occasionally  triumphs  over  both  the  disease  and  the 
treatment.  The  most  common  kinds  of  crisis  in  pleurisy,  are 
those  by  urine,  sweat,  or  haemorrhage  :  diarrhoea  is  also  frequently 
critical ;  a  crisis  by  expectoration  is  more  rare,  and  only  occurs 
in  the  case  of  pleuro-pneumonia.  In  some  instances,  an  erysip- 
elas, a  miliary  or  some  other  cutaneous  eruption,  and  even  jaun- 
dice, has  proved  critical ;  and  the  same  thing  has  sometimes  been 
observed  of  salivation  and  inflammation  of  the  parotids.  As  a 
general  rule  in  pleurisy,  pneumonia,  and  other  cases  of  pure 
inflammation,  it  may  be  stated,  that  we  o/ight  neither  to  disregard 
(much  less  disturb  by  too  active  treatment)  an  incipient  crisis, 
nor  yet  lose  precious  time  in  waiting  for  it. 

When  the  fever  and  pain  have  ceased,  the  disease  then  enters 

Clinic  of  La  Charite,  I  witnessed  this  transference  of  inflammation  to  the  peri- 
cardium and  arachnoid.  If  we  make  use  of  antimonial  medicines  in  this  case, 
we  ought  to  confine  ourselves  to  the  white  oxyd,  as  was  done  by  the  ancient 
physicians  of  La  Charite,  as  in  the  famous  potion  in  pleuritide.—(M.  L.) 

My  own  experience  leads  me  to  join  in  the  condemnation  of  tartar  emetic  in 
large  doses,  in  pure  pleurisy:  nothing  can  be  more  striking  than  the  difference 
of  effect  of  this  potent  remedy  in  this  disease  and  in  pneumonia;  and  nothing 
can  place  in  a  stronger  light  the  importance  ol  the  means  which  tend  to  dis- 
criminate the  two  diseases  in  practice.—  Transl. 

*  See  note,  page  22d.— Transl. 


TREATMENT    OF    PLEURISY. 


507 


the  chronic  stage,  or  that  of  absorption,  which  is  seldom  of  less 
than  a  month's  duration,  and  may  sometimes  extend  to  two  years, 
as  formerly  mentioned.  It  is  at  the  beginning  of  this  period 
that  blisters  to  the  affected  side  may  be  employed  with  advantage  ; 
later  in  the  disease  a  seton  is  preferable.  We  must  at  the  same 
time  assist  the  absorption  of  the  fluid  by  purgatives  and  diuretics. 
Acute  pleurisy  become  chronic  has  a  great  analogy  with  dropsy  ; 
and  indeed  it  was  only  by  confounding  these  two  diseases  together, 
that  hydrothorax  was  considered  so  common  an  affection  by 
several  physicians  of  the  last  century.  To  be  useful,  purgatives 
ought  to  be  pretty  frequently  repeated.  They  are  particularly 
indicated,  subsequently  to  blood-letting,  when  the  abundance  of 
the  effusion,  or  the  rapidity  of  its  formation,  and  the  general 
symptoms,  give  reason  to  presume  that  the  pleurisy  is  haemor- 
rhagic.  It  was  justly  remarked  by  Sydenham,  that  purgatives 
afford  the  best  means  of  checking  haemorrhagej  after  the  vessels 
have  been  emptied  by  blood-letting.  Diuretics  seem  to  have  no 
evident  effect  upon  the  absorption  unless  they  are  given  in  larger 
doses  than  is  customary.  I  am  in  the  habit  of  carrying  the 
acetate  of  potass  to  the  extent  of  six  drams,  or  even  to  two 
ounces,  in  the  day.  In  like  manner,  I  gradually  increase  the 
dose  of  nitre  from  forty  grains  to  three  or  four  drams,  if  the 
patient  bears  it  well :  and  with  this  latter  salt  I  sometimes  com- 
bine sal  ammoniac,  according  to  the  method  of  Triller.  I  have 
sometimes  also  given,  with  advantage,  the  extract  of  squills,  as 
recommended  by  Q,uarin,  viz.  in  a  minimum  dose  of  two  grains 
every  three  hours.  If  the  effusion  has  been  of  long  standing,  and 
there  is  no  hectic  fever  present,  it  is  often  of  use  to  combine 
bitters  with  our  diuretics,  and  to  administer  them  in  white  wine, 
as  in  the  formula  known  by  the  name  pf  the  bitter  and  diuretic 
wine  of  La  Charite*  Immediately  after  the  acute  stage,  I 
prefer  the  watery  infusion  of  digitalis,  beginning  with  the  dose 
of  eighteen  grains,  (to  the  pint  of  water,)  and  gradually  aug- 
menting it  to  half  a  dram  or  more  if  the  patient  bears  it  well. 
I  have  occasionally  used  with  benefit  urea,  in  doses  of  twelve 
grains  daily,  gradually  increased  to  a  dram  and  more.  In  res- 
pect of  diuretics  generally,  it  may  be  said  that  the  mode  of  evac- 
uation by  them  is,  next  to  that  by  sweat,  the  least  under  the  com- 
mand of  medicine.  Sometimes,  however,  they  are  wonderfully 
successful.  Two  years  since,  I  had  occasion  to  see,  in  consul- 
tation with  MM.  Cayol  and  Marjolin,  a  child,  who  had  labored 

*  According  to  the  formulary  of  Ratier  (p.  334)  this  is  made  by  the  infusion 
of  the  following  articles  in  two  pounds  of  wine  for  twenty-four  hours,  viz. 
Winter's  bark,  cinchona,  cinnamon,  of  each  an  ounce,  angelica,  squills,  juniper 
berries,  mace,  of  each  two  ounces;  leaves  of  wormwood  and  balm,  of  each  two 
handfuls.     The  dose  is  said  to  be  from  one  to  four  ounces  daily. —  Transl. 


508  TREATMENT    OF    PLEURISY. 

under  pleurisy  for  several  weeks,  and  in  whom  the  effusion  was 
so  copious  as  to  impress  us,  at  first,  unanimously,  with  the  neces- 
sity of  the  operation  of  empyema.  I  however  proposed  to  make 
trial  of  nitre  in  large  doses  ;  and  was  gratified  to  find,  at  the  end 
of  twenty-four  hours,  that  the  oppression  was  perceptibly  less, 
under  a  copious  flow  of  urine  which  had  been  excited  :  during 
the  following  days,  the  dilatation  of  the  affected  side  rapidly 
diminished,  and  the  patient  eventually  recovered  without  any  ope- 
ration. 

The  treatment  of  pleurisy  which  is  chronic  from  the  begin- 
ning,* does  not  differ  materially  from  the  acute  disease  become 
chronic  ;  and  indeed  we  must  be  contented  with  the  same  means, 
although  the  affections  are  of  very  different  severity.  Sometimes 
in  the  beginning  of  this  species,  we  may  take  away  blood  with 
benefit,  if  pain  is  occasionally  present,  and  if  the  fever  is  con- 
siderable, though  of  the  hectic  character.  But  we  must  be  on 
our  guard  not  to  pass  the  just  limits  ;  and  weaken  unnecessarily 
a  constitution  already  too  much  enfeebled.  Small  local  bleedings 
are  in  general  sufficient ;  and  it  is  better  to  repeat  these  occa- 
sionally than  to  make  them  too  copious.  Blisters,  caustic  issues, 
and  particularly  setons,  on  the  affected  side,  are  still  more  indi- 
cated in  this  variety  than  in  that  which  had  been  originally  acute : 
and  it  is  also  in  this  case,  more  especially,  that  we  must  combine 
tonics  with  our  diuretics,  particularly  bitters  and  those  denomi- 
nated anti-scorbutics. 

Of  Empyema  and  the  operation  of  Empyema. — The  name  of 
empyema  was  originally  applied  by  the  ancients  to  every  collec- 
tion of  purulent  matter  ;  it  was  subsequently  confined  to  effusions 
into  the  pleura  and  abscesses  of  the  lungs  ;  and  is  now  applied 
by  modern  surgeons  to  effusions  into  the  pleura  only  ;  hence  the 
names  of  empyema  of  pus,  of  blood,  of  water  and  air,  are  often 
used  as  synonymes  of  pleurisy,  haemothorax,  hydrothorax,  and 
pneumothorax.  With  the  exception  of  that  last  named,  these 
diseases  give  rise  to  symptoms  very  much  alike.  The  signs  by 
which  we  are  guided  in  determining  upon  the  operation  of  em- 
pyema, are  chiefly  these  : — the  dilatation  of  the  affected  side  : 
oedema  of  the  same  side,  and  arm,  or  the  proportionally  greater 
oedema  of  these  parts  when  the  affection  is  general ;  depression  of 
the  liver ;  displacement  of  the  heart  towards  the  side  free  from 
fluid.  We  have  already  shown  that  all  these  signs  (which  on  ex- 
amination will  be  found  referable  to  one  cause,  viz.  dilatation  of 
the  affected  side)  may  be  wanting ;  and  it  even  frequently  hap- 
pens that  at  the  very  time  when  an  operation  is  proper,  the  affected 

*  I  make  use  of  this  expression  for  want  of  a  better,  although  I  am  well  aware 
of  its  incorrectness. — Autlior. 


TREATMENT    OF    PLEURISY. 


509 


side,  although  full  of  pus,  is  smaller  than  the  opposite  one,  in 
consequence  of  the  absorption  which  has  already  taken  place, 
and  the  contraction  consequent  to  this.  But  in  all  cases  of  this 
kind,  the  results  of  percussion  and  auscultation  leave  no  doubt 
respecting  the  existence  of  the  effusion. 

There  are  two  cases  of  pleurisy  in  which  the  operation  of 
empyema  ought  to  be  performed.  The  first  is  when  in  an 
acute  pleurisy,  the  effusion  is  very  copious  from  the  begin- 
ning, and  increases  so  rapidly  as  to  give  rise,  after  a  few  days, 
to  a  general*  or  local  anasarca,  and  to  threaten  suffocation. 
This  is  the  case  which  I  shall  designate  acute  empyema.* 
The  second  case  is  that  which  I  term  chronic  empyema,  and  is 
either  the  consequence  of  a  pleurisy  essentially  and  originally 
chronic,  or  of  the  acute  disease  degenerated  to  this  state.  In 
such  circumstances,  when  oedema  of  the  affected  side  has  come 
on,  when  the  long  continuance  of  the  disease,  the  progressive 
emaciation  and  debility  of  the  patient,  and  the  failure  of  every 
measure  employed  to  produce  absorption,  leave  us  nothing  to 
expect  from  other  means,  we  are  justified  in  having  recourse  to 
the  operation.  This  operation,  however,  is  rarely  followed  by 
success,  owing  to  various  causes,  all  of  which  are  not  equally 
well  understood.  1.  The  first  of  these,  is  the  bad  condition  of 
the  lung  itself,  this  being  frequently  tuberculous.  This  is  no 
doubt  a  very  serious  evil ;  but  it  ought  not  to  be  considered  as 
amounting  to  an  absolute  prohibition  of  the  operation  ;  even  in 
the  case  where  pectoriloquy  is  discovered  in  the  upper  lobe  of 
the  compressed  lung,  provided  the  other  be  sound :  what  was 
formerly  stated  respecting  the  possibility  of  curing  phthisis,  and 
some  facts  to  be  noticed  hereafter,  suffice  to  prove,  that  we  must 
not  abandon  all  hope  of  cure  even  when  there  exists  so  serious  a 
complication  as  this.  2.  The  irritation  produced  on  the  surface 
of  the  pleura,  by  the  admission  of  air  into  the  chest,  has  parti- 
cularly engaged  the  attention  of  surgeons,  who  have  chiefly  re- 
ferred to  this  cause  the  great  and  offensive  discharge  which  too 
often  succeeds  the  operation,  and  carries  off  the  patient.  There 
can  be  no  doubt  that  the  admission  of  air  into  the  chest  affects 
the  action  of  the  organs  contained  in  it ;  but,  in  the  present  case, 
its  immediate  impression  is  not  on  the  pleura.  In  the  case  of 
acute  pleurisy,  or  such  as  was  so  originally,  the  pleura  is  invested 
with  a  false  membrane ;  while  in  the  chronic  variety,  there  is  at 
least  a   layer  of  thick   pultaceous  pus  between  it  and  the  air. 

*  For  a  strongly  marked  case  of  this  kind,  and  one  in  which  I  have  never 
censed  to  regret  the  non-performance  of  paracentesis,  I  refer  the  reader  to  Case 
XXV.  in  "  Original  Cases,"  &c.  p.  215.  I  have  denominated  this  disease  Idio- 
pathic Hydrothorax,  but  it  will  be  seen  from  the  Remarks  appended,  that  I  con- 
sidered it  at  the  time  to  be  the  case  described  in  the  text.—  Transl. 


510  TREATMENT    OP    PLEURISY. 

But  even  in  the  event  of  actual  contact,  the  air  could  only  at 
most  give  rise  to  a  more  acute  state  of  inflammation,  which 
would  not  in  itself  prevent  the  cure.  On  the  contrary,  the  false 
membranes  thereby  produced,  being  susceptible  of  transformation 
into  serous  tissue,  might  unite  the  pleura  pulmonalis  and  costalis 
together,  and  thereby  tend  to  facilitate  me  recovery.  3.  But 
the  cause  which,  in  my  opinion,  affords  the  greatest  obstacle  to 
the  success  of  the  operation,  is  the  compression  of  the  lung 
against  the  spine  and  mediastinum  and  the  nature  of  the  invest- 
ing false  membrane.  The  viscus,  from  long  compression,  has 
lost  its  elasticity  and  expansibility ;  it  is  penetrated  with  diffi- 
culty by  the  inspired  air,  and  only  recovers  very  slowly  the  di- 
mensions which  it  had  before  the  disease.  It  never,  indeed,  re- 
turns to  its  original  size.  (See  the  section  On  Contraction  of  the 
Chest.)  If  the  investing  false  membrane  is  of  the  kind  which 
has  a  tendency  to  be  converted  into  fibrous  tissue,  as  happens  in 
the  case  of  hsemorrhagic  pleurisy,  the  dilatation  of  the  chest  be- 
comes more  difficult  still ;  as  it  cannot  take  place  unless  this  very 
strong  membrane  relaxes  and  gives  way,  which  can  only  be  a 
work  of  time.  Meanwhile  the  atmospheric  air  continually  irri- 
tates the  exhalent  surface  of  this  partially  organized  membrane, 
and  excites  a  purulent  discharge  so  copious  as  to  exhaust  the 
patient's  strength,  while  it  is  productive  of  no  local  benefit,  the 
parts  being  still  too  far  apart  to  be  agglutinated.  For  this  rea- 
son, the  acute  empyema  affords  more  chance  of  success  than  the 
chronic ;  and  the  variety  of  the  latter,  which  is  chronic  from  the 
beginning,  affords  a  better  prospect  than  the  acute  degenerated 
to  this  state,  although  the  condition  of  the  fluid  in  the  former 
seems  more  unfavorable. 

The  mode  of  operation  commonly  employed  at  present  does 
not  seem  susceptible  of  much  improvement.  I  presume  no  one 
will  ever  think  of  reviving  the  perforation  of  the  rib  employed 
by  the  followers  of  Hippocrates,  since  it  has  many  disadvantages 
peculiar  to  itself,  and  no  advantage  over  the  common  methods. 
Puncture  of  an  intercostal  space  by  means  of  a  trocar  has  been 
repeatedly  had  recourse  to.  It  was  employed  by  Morand,  among 
others,  without  success.  M.  Recamier  has  several  times  per- 
formed this  operation,  usuing  a  very  small  trocar  ;  and  I  have 
myself  repeatedly  done  so,  but  without  ever  having  obtained  any 
permanent  benefit  from  it.  This  operation,  however,  is  not  at- 
tended by  any  inconvenience,  and  gives  always  temporary  relief, 
— but  only  temporary.  As  soon  as  the  instrument  is  withdrawn, 
the  adaptation  of  the  wound  of  the  skin  and  of  the  intercostal 
muscles  is  destroyed  :  no  discharge  takes  place  ;  the  wound  heals 
entirely  in  the  course  of  a  few  days,  and  the  chest  fills  anew. 
If  this  measure  should  ever  prove  successful,  I  think  it  will  be 


TREATMENT    OF    PLEURISY. 


511 


in  cases  of  acute  empyema,  in  which  successive  punctures  might, 
perhaps,  at  once  aid  the  absorption,  and  accelerate  the  conversion 
of  the  false  membranes.  There  are  two  other  cases  in  which  I 
willingly  have  recourse  to  puncture  ;  1  st.  when  the  patient  is  so 
debilitated,  as  to  occasion  apprehension  lest  the  complete  dis- 
charge of  the  fluid  might  occasion  a  dangerous  syncope ;  2nd. 
as  a  means  of  relief  in  cases  which  are  incurable,  on  account  of 
the  co-existence  of  numerous  tuberculous  excavations.  When 
there  exists  considerable  oedema  of  the  side,  it  is  sometimes  im- 
possible to  perform  this  operation  from  the  inability  of  the  sur- 
geon to  distinguish  the  intercostal  spaces. 

The  place  of  election,  commonly  adopted  by  surgeons,  for  this 
operation,  is  the  most  dependent  point  in  the  anterior  and  lateral 
parts  of  the  chest.  This  rule,  however,  cannot  hold  good  con- 
stantly, since  the  most  dependenl  point  varies  with  the  position 
of  the  patient.  The  natural  posture  of  a  patient  affected  with 
empyema  is  to  lie  on  the  diseased  side ;  and  in  this  case  the  most 
depending  point  is  the  space  between  the  fifth  and  sixth  ribs.  Ma- 
ny other  reasons  point  out  this  spot  as  being  the  best  suited  for 
the  operation.  For  instance,  we  know  that  the  upper  lobe  ad- 
heres to  the  ribs  more  frequently  than  any  other  part  of  the  lungs, 
and  that  the  lower  lobe  is  frequently  attached  to  the  diaphragm. 
On  the  right  side,  we  know  that  an  enlarged  liver  frequently 
reaches  as  high  as  the  sixth  or  even  the  fifth  rib  ;  and  that,  on 
both  sides,  the  thickest  false  membranes,  and  consequently  adhe- 
sions, exist  at  the  junction  of  the  diaphragm  with  the  walls  of 
the  chest.  Finally,  we  know  that  the  greatest  portion  of  the 
effused  fluid  is  collected  about  the  middle  of  the  side.  The  in- 
tercostal space  mentioned,  ought,  therefore,  to  be  preferred,  and 
the  best  point  is  a  little  anterior  to  the  digitations  of  the  serratus 
major.  Should  there  chance  to  be  any  old  adhesions  in  this 
point,  we  shall  readily  and  certainly  discover  them  by  means  of 
some  remains  of  respiration  over  their  site.  If,  then,  we  are  as- 
sured, by  repeated  examination,  that  the  sound  on  percussion  is 
dull  over  this  point  (or  indeed  over  any  other)  and  that  the  sound 
of  respiration  is  wanting,  we  may  safely  make  an  incision,  and 
with  less  caution  and  slowness  than  are  commonly  used.  I  for- 
merly showed  that  the  fear  of  wounding  an  adherent  and  com- 
pressed lung  has  been  exaggerated.  I  am  well  assured  that  this 
operation  will  become  more  common,  and  more  frequently  useful, 
in  proportion  as  the  employment  of  auscultation  is  extended. 
This  method  of  exploration,  either  singly  or  conjoined  with  per- 
cussion (and  sometimes  with^succussion),  enabling  us  to  recognize 
effusions  at  their  origin,  we  have  it  thereby  in  our  power  to 
operate  early  and  consequently  with  greater  chance  of  success. 
Hitherto,  in  fact,  the  simple  empyema  and  idiopathic  hydrothorax 


512  PLEUROPNEUMONIA. 

have  never  been  distinguished  until  the  disease  was  of  long  stand- 
ing and  of  great  extent ;  and,  indeed,  even  in  this  period  of  their 
progress,  these  affections  have  frequently  escaped  the  notice  of 
the  best  informed  physicians  and  surgeons:  how  much  more 
likely,  then,  are  the  slighter  cases  which  offer  most  chance  of 
success,  to  be  overlooked  ?  I  do  not  think  I  go  too  far,  when  I 
assert  that,  in  the  state  in  which  the  science  was  left  by  Aven- 
brugger  and  Corvisart,  empyema  was  not  recognized  until  after 
the  effusion  had  become  very  great,  or  unless  it  had  been  pre- 
ceded by  the  symptoms  of  manifest  pleurisy.  It  has  lately  oc- 
curred to  me,  from  witnessing  the  effect  of  the  piston  cupping- 
glass,  that  the  employment  of  this  instrument  might  perhaps 
enable  us  to  overcome  the  chief  obstacle  to  the  success  of  the 
operation,  viz.  the  difficulty  of  procuring  the  expansion  of  the 
compressed  lung.  Accordingly*,  I  have  it  in  contemplation,  at 
the  first  opportunity  that  offers  for  performing  the  operation  of 
empyema,  to  apply  the  exhausting  glass  over  the  wound,  imme- 
diately after  the  discharge  of  the  liquid,  and  to  produce  a  vacuum 
in  the  chest,  more  or  less  quickly,  continuously,  and  completely, 
according  to  the  effects ;  taking  care  to  defend  the  skin  from  the 
pressure  of  the  glass  by  interposing  a  piece  of  leather,  and  by 
using  in  succession  glasses  of  different  diameters.*  • 

Sect.  X. — Of  Plenro-pneumonia. 

Pleurisy  is  frequently  conjoined  with  pneumonia  ;  and  it  is  no 
doubt  from  this  circumstance,  that  these  diseases  have  been  so 
long  confounded.  However,  even  in  the  cases  in  which  they 
are  conjoined,  it  frequently  happens  that  one  of  the  affections  is 
so  much  more  violent  than  the  other,  as  to  render  the  latter  a 
complication  of  hardly  any  consequence.  On  this  account,  we 
can  distinguish   in  practice  three  different  varieties  of  pleuro- 

*  For  a  minute  and  most  elaborate  history  of  the  operation  of  empyema,  from 
the  earliest  times,  I  refer  the  reader  to  Sprengel's  History  of  Medicine,  vol.  ix. 
p.  1 ;  and  for  a  very  complete  and  scientific  view  of  the  whole  subject,  in  the 
actual  state  of  our  knowledge,  I  refer  him  to  the  article  Empyema  in  the  Cyclo- 
paedia of  Pract.  Med.  written  by  Dr.  Townsend,  a  most  able  physician  and  prac- 
tical auscultator.  The  subject  is  treated  of  by  all  our  best  surgical  writers  ;  and 
I  would  particularly  refer  the  student  to  the  following  works  :  Sharp's  Critical 
Enquiry;  Warner's  Cases  in  Surgery;  Kirkland's  Medical  Surgery  ;  White's 
Surgery  ;  Hey's  Practical  Observations ;  Pearson's  Principles  of  Surgery  ;  C. 
Bell's  Operative  Surgery  ;  to  many  cases  in  the  various  Medical  Journals,  and 
particularly  to  the  papers  of  Dr.  Hastings  and  Mr.  Jovvett  referred  to  in  a  for- 
mer note.  The  last  named  writer  proposes  to  revive,  on  an  improved  plan,  the 
method  of  removing  the  fluid  by  means  of  a  syringe,  as  formerly  recommended 
by  Scultetus  and  Anel ;  (See  Jourdan's  translation  of  Sprengel,  t.  ix.  p.  23.  35;) 
a  proposition  that  seems  to  hold  out  many  advantages,  in  certain  cases.  This 
plan,  if  successfully  put  in  execution,  will  do  away  with  the  necessity  of  the 
more  problematical  suggestion  in  the  text,  of  attempting  to  elevate  the  com- 
pressed lung  by  means  of  an  air  pump.—  Transl. 


PLEURO-PNKUMONIA. 


513 


pneumonia,  which  present  real  differences  in  their  progress,  and 
in  the  mode  of  treatment  best  suited  to  them.  These  are — 1. 
pneumonia  complicated  with  slight  pleurisy  ;  2.  pleurisy  compli- 
cated with  a  slight  pneumonia ;  and  3.  pleuro-pneumonia,  pro- 
perly so  called,  in  which  both  affections  exist  in  a  nearly  equal 
degree. 

1.  Pneumonia  complicated  with  slight  pleurisy. — There  are 
few  examples  of  simple  pneumonia,  if  by  this  term  we  understand 
such  only  as  are  unaccompanied  by  false  membranes  on  any  part 
of  the  pleura  pulmonalis  or  costalis,  or  by   serous  effusion  even 
in  small  quantity.     In  almost  every  case  of  pneumonia,  when  the 
inflammation  reaches  the  surface  of  the  lungs  in  any  point,  the 
contiguous  portions  of  the  pleura  inflames  and  becomes  invested 
with  an  albuminous  false  membrane.     This  membrane  is  usually 
thin,  and  is  frequently  confined  exactly  to  that  portion  of  the 
pleura  pulmonalis  which   corresponds  with  the  hepatized  space 
that  has   reached   the   surface.     In    this  case  the   inflammation 
seems  to  have  a  greater  tendency  to  propagate  itself  by  contiguity 
than  by  continuity  ;  since  we  frequently  find  a  false  membrane  of 
the  same  kind  on  the  corresponding  portion  of  the  costal  pleura. 
If  the   hepatization  occupies  only  a  part  of  the  lung,   it  is  ac- 
companied by  a  slight  sero-purulent  effusion  ;  but   if  nearly  the 
whole  lung  is  so  affected,  then  there  is  no  effusion  whatever ; 
only  we  observe   on  its  surface  a  very  thin  and   imperfect  false 
membrane,  thicker   along  the  edges  and  in  the  interlobular  fis- 
sures, and  also  in  some  other  points,  where  the  inflammation  had 
first  reached  the  surface.     This  is  the  most  common  variety  of 
what  is  called  dry  pleurisy  ;  but  it  is  to  be  remembered  that   in 
cases  of  this  kind,  the  pleurisy  is  evidently  a  mere  accidental 
consequence,   of  little   importance  in  itself,    and  scarcely  at  all 
modifying  the  severity  or  the  progress  of  the  pneumonia.     In 
this  particular  state  of  the  disease,  it  would  be  extremely  diffi- 
cult to  distinguish  the  pneumonia  from  a  pleurisy  with   copious 
effusion,  if  we  had  not  seen  the  patient  before  this  period :  we 
should  have  here  as  complete  an  abscess  of  the  thoracic  reso- 
nance as  if  the  whole  surface  of  the  lung  were  covered  by  a 
pleuritic  effusion,  while  the  stitch,  which  is  by  no  means  uncom- 
mon at  the  time  when  the   inflammation   reaches  the  surface  of 
the  lung,  would  further  lead  us  to   suspect  an   affection  of  the 
pleura.     However,  even  in  these  circumstances,  it  is  still  in  Our 
power  to  obtain  a  more  accurate   diagnosis.     When  the  lung  is 
completely  hepatized,  without  any  accompanying  effusion,   there 
exists  always  a  strongly   marked   bronchophony,  almost  like  pec- 
toriloquy, in  different  points,  and  particularly  towards  the  sum- 
mit and  roots  of  the  lungs, — a  thing  which   never  exists  in  the 
same  degree,  or  over  the  same  extent,  in  pleurisy  or  pleuro- 
65 


514  PLEUROPNEUMONIA. 

pneumonia.  If  we  have  had  opportunities  of  seeing  the  patient 
from  the  origin  of  the  disease,  the  diagnosis  will  be  much  more 
easy ;  or,  rather,  any  mistake  will  be  impossible.  In  the  case 
of  pneumonia,  the  existence  of  the  crepitous  rhonchus  previously 
to  the  complete  disappearance  of  the  respiratory  murmur,  and 
the  gradual  diminution  of  the  sound  on  percussion,  will  leave  no 
doubt  of  the  nature  of  the  affection  :  in  pleurisy,  the  loss  of  re- 
sonance is  sudden  or  almost  without  gradation,  and  exists  at  once 
over  the  whole  of  the  affected  side,  at  least  in  cases  in  which 
the  lungs  had  been  previously  healthy  and  without  adhesions. 
Moreover,  in  the  case  of  pleurisy,  aegophony  is  always  percepti- 
ble, at  least  for  one  or  two  days. 

2.  Pleurisy  complicated  ivith  slight  pneumonia. — In  the  case  of 
a  severe  pleurisy,  attended  by  an  effusion  sufficiently  abundant 
and  rapid  suddenly  to  compress  the  lung  upon  its  roots,  it  is  by 
no  means  uncommon  for  an  inflammation  of  some  points  of  the 
pulmonary  substance  to  arise  at  the  same  time,  particularly  in 
the  lower  lobe.  These  points  of  inflammation  frequently  remain 
distinct,  and  consequently  of  small  extent ;  and  constitute  one  of 
the  varieties  of  the  affection  which  has  been  termed  lobula  pneu- 
monia by  some  recent  observers.  The  pulmonary  inflammation 
is  here  very  remarkably  modified  by  the  pleuritic  effusion.  The 
compression  produced  by  this  clearly  moderates  the  inflammatory 
action  ;  and  it  is  no  doubt  owing  to  this  cause  that  in  the  present 
case,  more  than  any  other,  the  phlogosis  remains  confined  to 
some  particular  lobules.  It  also  very  rarely  reaches  the  suppu- 
rative stage ;  its  resolution  is  much  slower,  and  its  anatomical 
characters  are  quite  peculiar.  The  hepatized  parts  are  here  in 
the  first  instance  much  more  flabby,  and  less  solid  than  in  simple 
pneumonia  ;  and  become  converted  into  a  substance  completely 
resembling,  both  in  appearance  and  consistence,  muscular  flesh, 
which  has  been  beaten  to  make  it  tender.  In  this  state  it  has  of 
course  lost  the  granulated  surface  characteristic  of  hepatization  ; 
it  is  completely  flabby,  and  is  of  a  red  or  violet  color,  sometimes 
with  a  tint  of  greyish.  This  is  the  lesion  to  which  I  give  the 
name  of  carnification,  a  term  which  has  sometimes  been  very 
improperly  applied  to  common  hepatization.  I  have  constantly 
met  with  it  in  the  case  in  question,  and  never  in  any  other.  I 
am,  however,  disposed  to  believe,  that  the  imperfect  resolution 
of  the  hsernoptysical  infarction,  when  complicated  with  pleuritic 
effusion,  sometimes  produces  the  same  effect.  Pulmonary  sub- 
stance thus  carnified,  presents  a  homogeneous  texture,  is  supple 
and  compact,  and  retains  no  trace  of  air-cells  :  it,  however,  still 
exhibits  the  ramification  of  the  bronchial  tubes  and  vessels.  It 
is  as  dry  as  muscle,  and  does  not  contain  a  particle  of  air.  The 
resolution  of  the  inflamed  luns  is  much  slower  under  the  in- 


PLEURO-PNEUMONIA.  515 

fluence  of  the  pleuritic  effusion  than  in  other  circumstances ;  as 
I  have  sometimes  found  the  state  of  carnification  very  strongly 
marked,  after  all  symptoms  of  pneumonia  had  disappeared  for 
more  than  two  months.  In  proportion,  however,  as  thp  resolution 
is  near  its  completion,  the  carnified  spot  becomes  first  paler,  then 
violet-pale,  and  finally  flaxen-grey  :  while  the  original  vesicular 
texture  of  the  healthy  viscus  is  simultaneously  developed.  I 
have  very  rarely  had  an  opportunity  of  observing  the  traces  of 
resolution  when  the  inflammation  had  reached  the  stage  of  puru- 
lent infiltration,  under  the  influence  of  a  pleuritic  effusion. — 
Howeter,  in  some  instances  of  pleuro-pneumonia,  and  in  subjects 
who  had  died  of  some  concomitant  affection,  one,  two,  or  even 
three  weeks  after  the  complete  cessation  of  every  inflammatory 
symptom,  and,  indeed,  of  every  sign  of  pleurisy  except  such  as 
depend  immediately  on  the  presence  of  a  fluid  in  the  pleura, — 
I  have  found  the  affected  portions  of  the  lung  flabby,  dry,  and 
yellowish,  with  the  vesicular  structure  discoverable  in  some 
points,  but  the  vesicles  apparently  filled  with  a  half-concrete 
pus. 

When  a  pneumonia,  even  slight,  supervenes  to  a  pleurisy  with 
copious  effusion,  it  is  almost  always  recognized  by  means  of.  the 
crepitous  rhonchus,  which  is  usually  observed  towards  the  roots 
of  the  lungs,  under  the  scapula,  in  the  axilla  or  a  little  beneath 
the  clavicles,  that  is,  in  the  parts  of  the  lungs  which  are  with 
most  difficulty  compressed  by  the  effusion. — It  is,  moreover,  to 
be  remarked  in  this  place,  that  the  complication  just  described 
can  only  take  place  at  the  onset  of  the  disease,  and  when  the 
effusion  is  still  small  in  quantity  ;  since  we  know  that  a  lung 
thoroughly  compressed  is  no  longer  susceptible  of  inflammation. 
And  this  case  is  analogous  to  others  met  with  in  practice.  When 
a  violent  inflammation  is  produced  by  a  sprain,  or  luxation,  or 
burn,  the  application  of  a  compressing  bandage  is  a  sure  means 
of  moderating,  in  a  great  degree,  the  intensity  and  extent  of  the 
inflammation  ;  and  the  same  result  has  been  frequently  obtained 
in  erysipelas. 

3.  Pleuro-pneumonia,  properly  so  called. — The  conjunction 
of  an  inflammation  of  the  whole  or  a  part  of  the  pleura  with 
pretty  copious  effusion,  and  a  severe  pneumonia,  is  a  much  rarer 
case  than  either  of  the  two  just  described.  Pleurisy  conjoined 
with  pneumonia  does  not  increase  the  danger  of  the  latter ;  on 
the  contrary,  it  lessens  it,  as  we  have  just  stated,  by  exerting  a 
compressing  force  on  the  lung.  On  the  other  hand,  the  pneu- 
monia at  first  augments  the  danger  of  the  pleurisy,  (which  is 
rarely  fatal  in  the  acute  stage,)  but  it  occasions  a  more  rapid 
absorption  of  the  effusion,  by  preventing  this  from  being  so  copi- 
ous as  in  simple  pleurisy,  the  inflammation  rendering  the  lung  less 


516  PLEURO-PNEHMONIA. 

compressible.  C&teris  paribus,  then,  pleuropneumonia  ought  to 
be  regarded  as  less  dangerous  than  either  the  simple  pleurisy  or 
pneumonia ;  and  I  think  this  opinion  is  supported  no  less  by  ex- 
perience than  by  reasoning. 

Pleuro-pneumonia  is  easily  recognized  by  the  re-union  of  the 
signs  of  pleurisy  and  pneumonia.  Some  of  the  pathognomonic 
signs  are  even  more  permanent  in  this,  'than  in  either  of  the 
simple  affections,  for  the  reason  just  stated,  that  they  mutually 
impede  and  retard  one  another's  progress.  We  thus  often  observe 
the  crepitous  rhonchus  on  the  one  hand,  and  aegophony  on  the 
other,  up  to  the  period  of  convalescence.  In  cases  of  this  kind, 
aegophony  is  seldom  simple :  it  is  perceptible  only  at  the  roots 
of  the  lungs  around  the  lower  angle  of  the  scapula  ;  and,  on 
account  of  the  vicinity  of  the  large  bronchial  trunks  and  the 
density  of  the  pulmonary  substance,  it  is  usually  combined  with 
a  marked  bronchophony.  This  case  of  the  conjunction  of  these 
two  phenomena,  is  that  in  which  we  frequently  observe  the  com- 
plete resemblance  to  the  squeaking  of  Punchinello.* 

The  treatment  of  pleuro-pneumonia  must  be  regulated  accord- 
ing to  the  predominance  of  either  affection.  1  shall,  therefore, 
content  myself  with  referring  to  what  has  been  already  said  re- 
specting these  individually .f 

*  M.  Chomel  notices  a  case  of  pleuro-pneumonia,  in  which  the  crepitous  rhon- 
chus was  only  perceptible  during  the  inspiration  which  succeeded  the  efl'orl  of 
coughing.  The  rhonchus  was  accompanied  by  aegophony,  the  bronchial  respira- 
tion, &c.  and  denoted,  according  to  M.  Chomel,  that  the  affection  of  the  pleura 
corresponded  exactly  with  that  of  the  lungs.  (Diet.  de.  Mtd.t.  xvii.  art.  Pneumo- 
nie.)  This  conclusion  appears  to  me  by  no  means  justifiable  ;  for  every  one  has 
had  occasion  to  notice  cases  in  which  not  merely  the  crepitous  rhonchus  but  al- 
so the  cavernous  rhonchus  and  indeed  all  the  varieties  of  the  bronchial  rhonchus, 
were  perceptible  only  during  fits  of  coughing.  All  that  is  necessary  to  produce 
this  result  is,  that  the  part  affected  lies  deep  and  at  a  distance  from  that  to  which 
the  ear  or  instrument  is  applied.  Thus  we  often  observe  the  same  thing  in 
lobular  pneumonia,  which  is  usually  central,  more  particularly  if  there  exists,  at 
the  same  time,  a  pulmonary  catarrh.  M.  Chomel's  remark  is  not  therefore 
new  ;  and  indeed  it  had  been  previously  made  by  Laennec  ;  nay,  more,  it  might 
have  been,  that  the  supposed  pleuro-pneumonia  of  M.  Chomel,  was  only  a  sim- 
ple pneumonia  which  had  reached  the  stage  of  hepatization  at  the  circumference 
of  the  lungs,  but  was  less  advanced  towards  their  center, — from  which  condition 
of  parts  would  result  the  bronchial  respiration  and  bronchophony  (taken  for 
aegophony)  from  the  surface,  and  the  crepitous  rhonchus  from  the  deeper  parts, 
— which  last,  owing  to  its  remoteness,  would  only  be  perceptible  during  the  fits 
of  coughing. — (M.  L.) 

t  LITERATURE  OF  PLEURISY. 

1537.  Turinus  (A.)  De  Curatione  Pleuritidis  per  vensesectionem.     Basil.  4to. 

1549.  Arma  (J.  F.)  De  Pleuritide.     Ferrara.  8vo. 

1562.  Bulleyn  (W.)  Regiment  against  the  Pleurisie.     Lond.  8vo. 

1564.  Cassanus  (F.)De  Vensesectione  in  Pleuritide.     Patav.  12mo. 

1622.  Moreau  (R.)  De  Missione  sanguinis  in  Pleuritide.     Par.  8vo. 

1634.  Benedictus  (J.  C.)  Tutelaris  columna,  qua   statuitur  pleuritidem  fieri  dum 
una  pulmonis  ala  afficitur.     Rom.  4to. 


IDIOPATHIC    HYDROTHORAX. 


CHAPTER  II. 


OF    HYDROTHORAX. 


.17 


This  disease  is  considered  by  many  practitioners,  and  by  extra- 
prbfessional  persons  generally,  as  a  very  common  disease,  and  a 
frequent  cause  of  death.  When  truly  idiopathic,  however,  and 
exisiing  in  a  degree  sufficient  to  occasion  death  by  itself,  I  con- 
sider it  as  one  of  the  rarest  diseases  ;  and  do  not  think  we  are 
justified  in  rating  its  fatality  higher  than  one  in  two  thousand 
deaths.*     I  have  often  seen  practitioners,  who  were  but  imper- 

1641.  Moreau  (R.)  De  loco  affecto  in  Pleuritide.     Par.  8vo. 
1657.  Fontanus  (G.)  Apologeticon  circa  Pleuritidis  ideam,  &c.     Lugd.  4to. 
1664.  Diemerbroeck  (J.  de)  Disput.  Pract.  De  morbis  capitis  et  thoracis.  Utr.  12mo. 
1672.  Banda  (A.)  Discours  contre  l'abus  de  la  Saignee  dans  les  Pleurisies.  Sed.  8vo. 
1683.  Bellini  (L.)  De  Urinis  el  Pulsibus. .  .De  morbis  capitis  et  Pectoris.  Bon.  4to. 
1686.  Baronius  (V.)  De  PleuripneumoniaFlaminiam  infestante.Lib.  ii.  Forol.  4to. 
1690.   Knisel  (J    S.)  Historia  Pleuritidis  et  abscessus  pectoris.      Tub.  4to. 
1692.  Campen  (C.  Von)  Collectanea  de  pleuritide  et  apoplexia.     Breda.  8vo. 

1701.  Fonseca  (Rod.  A.)  Pleurologia,  de  Pleuritide  ejusque  curatione.  Lisb.  4to. 

1702.  Pascoli  (A.)  Observationes  de  pleuritide.     Venet.  8vo. 

1713.  Verna  (J.  B.)  Princeps  Morborum  Acutorum  Pleuritis.      Venet.  4to. 
1735.  Carnerarius  et  Seeger.     De  Pleuritide  maligna,  (Hal.  Dis.  II.) 
1740.  Triller  (M.  A.)  Succincta  Comment,  de  Pleuritide.     Francf.  8vo. 
1742.  Tennent  (J.)   Epist.  to   Dr.  Mead   on  the  Pleurisy,  &c.  of  Virginia. — 

Edin.  12mo. 
1759.  Bouillet   (J.   H.    N.)    Memoire    sur   les    pleuro-peripneumonies    epid. — 

Beziers.  4to. 

1761.  Zeviani  (G.  V.)  Delia  Rachitide  e  della  Pleuritide.      Verona.  4to. 

1762.  Flemyng  (M .,  M.D.)  Adhes.  of  the  lungs   to  the   Pleura   considered. — 

Lond.  8vo. 
1779.  Musgrave  (S.,M.D.)Gulstonian  Lectures. — II.  On  Pleurisy,  &c.  Lond.  8vo. 
1786.  Triller  (D.  W.)  Abhandlung  voin  Seitenstechen.     Leips.  8vo. 

1789.  Saalmann  (F.,  M.D.)  Descriptio  Pleuritidis,  &c.     Mon.  W.  8vo. 

1790.  Sachtleben  (D.  W.)  Bemerk.  ueber  brustenzundung.      Goett.  8vo. 

1791.  Fiorani  (A.)  Saggio  sopra  la  pleuritide  biliosa.     Firenze.  8vo. 
1793.  Maschke  (G.  T.)  Historia  litis  de  loco  V.  S.  in  Pleuritide.     Hal.  4to. 
1803.  Conradi  (J.  W.  H.)  Pneumonie    und  Pleuritis  in  nosologischer  und  thera- 

peutischer  hinsiclit.     Marb.  8vo. 
1803.  Racine  (C.)  Rech.  sur  la  pleurisie  et  la  Peripn.  latente  chronique.     Par. 
1808.  Broussais  (F.  J.  V.)  Phlegmasies  Chroniques.     Par.  8vo. 
1820.  Pinel  et  Brichteau.  Diet,  des  Sc.  M.  (Art.  Pleurisie)  t.  53.     Par. 
1826.  Andral  (G.)  Clinique  Medicale,  t.  iii.     Par.    8vo. 
1827. .  Chomel  Diet,  de  Med.  (Art.  Pleurisie)  t.  17.     Par. 
1834.  Law.     Cyclopsed.  of  Pract.  Med.  (Art.  Pleurisy.)  vol.  iii. 

Cullen,  Burserius,  Darwin,  Frank,  Pinel,  Good,  &c.  Transl. 

*  Dr.  Darwell  goes  further,  and  altogether  denies  the  existence  of  such  a  dis- 
ease asMdiopathic  hydrothorax.  "  There  is  no  such  disease  (he  says)  as  hydro- 
thorax  independent  of  inflammation  of  the  pleura  or  organic  disease  of  some 
other  part."  (Cycl.  of  Pract.  Med.  vol.  ii.  p.  519.)  This,  I  think,  is  carrying 
the  point  too  far,  although  I  fully  coincide  with  Laennec  as  to  the  extreme  rarity 
of  the  idiopathic  affection. —  Transl. 

The  rarity  of  idiopathic  hydrothorax  must  be  regarded  as  still  more  so, 
since  researches  made  in  France  and  England  have  shown  that  dropsies  whose 
organic  cause  had  been  fruitlessly  sought  for,  must  be  referred  to  a  special  alter- 


518  IDIOPATHIC    HYDROTHORAX. 

fectly  acquainted  with  morbid  anatomy,  and  consequently,  very 
ignorant  of  diagnosis,  mistake  for  this  affection  hypertrophy  of 
the  heart,  aneurism  of  the  aorta,  irregular  consumption,  and  even 
scirrhus  of  the  stomach  or  liver, — when  there  was  no  co-existing , 
effusion  into  the  pleura,  or,  at  least,  none  other  except  what  took 
place  immediately  preceding  death.  Corvisart  formerly  pointed 
out  these  mistakes,  particularly  in  regard  to  the  two  first-named 
diseases.  One  circumstance  which  has  more  especially  led  to  the 
belief  of  the  frequency  of  this  disease,  is  the  common  mistake  of 
taking  a  sero-purulent  effusion  for  it.  This  has  arisen  from  the 
transparency  of  a  part  of  these  effusions.  Indeed,  it  is  only 
within  these  few  years  that  the  nature  of  the  pleuritic  effusion 
has  been  properly  known ;  and  the  mistake  we  have  mentioned 
has  been  made  by  men  of  great  eminence  at  no  very  remote  period. 
For  example,  Morand  gives  under  the  name  of  dropsy  of  the 
chest,  a  case  of  pleurisy  cured  by  the  operation  of  empyema.* 

Sect.  t. — Of  Idiopathic  Hydrothorax. 

Idiopathic  hydrothorax  commonly  exists  only  on  one  side. 
Its  anatomical  characters  are  simply  an  accumulation  of  serum 
in  the  cavity  of  the  pleura ;  this  membrane  being  quite  healthy 
in  other  respects  ;  and  the  lung  being  compressed  towards  the 
mediastinum,  flaccid,  and  destitute  of  air,  as  in  cases  of  pleuritic 
effusion.  When  the  effusion  is  very  great,  the  affected  side  is 
evidently  larger  than  the  other.  I  have  seen  this  when  there  was 
no  other  dropsical  affection,  nor  any  organic  lesion  to  which  it 
could  be  attributed.  In  one  case  of  this  kind  the  right  pleura 
contained  twelve  pounds  of  a  colorless  and  limpid  serum,  and 
seemed  in  other  respects  quite  healthy. 

Signs  and  symptoms — The  chief  and  almost  the  only  symptom 

ation  of  the  kidneys,  an  alteration  which  coincides  with  the  presence  of  uric 
acid  in  the  blood  and  albumen  in  the  urine.  Long  before  Dr.  Bright  called 
the  attention  of  physicians  in  a  particular  manner  to  the  lesion  of  the  kidneys 
which  bears  his  name,  I  published  a  case  in  the  first  edition  of  my  Clinique 
Medicale,  and  finding,  along  with  this  granulated  state  of  the  kidneys,  a  dropsy 
which  I  could  not  account  for  by  any  other  alteration,  I  asked  if  this  dropsy 
should  not  be  considered  as  proceeding  from  the  degeneration  of  the  organs 
which  secreted  the  urine.  In  one  of  the  cases  where  I  found  the  greatest 
quantity  of  albumen  precipitated  from  the  urine  by  nitric  acid,  the  most  consid- 
erable serous  effusion  consisted  of  a  hydrothorax  of  the  left  side.  There  were, 
at  the  same  time,  anasarca  and  ascites  :  but  the  effusion  in  the  pleura  was  greater 
than  in  the  peritoneum.  After  a  long  sickness,  which  gave  rise  to  serious  appre- 
hensions, the  serous  effusions  were  absorbed,  the  albuminous  dispositions  in 
the  urine  disappeared,  and  for  three  years  the  health  of  the  individual  has  been 
excellent  in  all  respects.— Andral. 

Mem.  de  1  Acad,  de  Chir.  torn,  ii.  p.  545. — Our  periodical  literature  abounds 
with  mistakes  ofthis  kind  :  see  a  remarkable  instance  in  the  Edin.  Journ.  vol. 
xvi.  p.  529.  See  also  Good's  Study  of  Medicine  (hydrothorax)  where  the  same 
mistake  is  committed. —  Transl. 


IDIOPATHIC    IIYDROTHORAX. 


519 


of  this  disease  is  the  impeded  respiration.  Percussion  affords  the 
dead  sound,  and  the  stethoscope  indicates  the  absence  of  respira- 
tion every  where  except  at  the  roots  of  the  lung.  At  the  time  of 
the  publication  of  the  first  edition  of  this  work,  I  imagined  that 
aegophony  ought  also  to  exist  in  this  case  ;  and  since  then  I  have 
more  than  once  proved  the  correctness  of  this  opinion.  This  was 
the  case  in  the  two  following  examples  : — 1.  Last  year  a  woman 
came  into  the  hospital  with  every  sign  of  hypertrophy  and  dila- 
tation of  the  heart,  and  of  an  effusion  in  each  side  of  the  chest. 
The  effusion  was,  in  particular,  very  abundant  on  the  left  side. 
In  this  case  eegophony  was  distinct  on  both  sides.  As  there 
was  neither  fever  nor  stitch  present,  I  looked  upon  the  effu- 
sion as  serous,  and  prescribed  the  acetate  of  potass,  to  the 
amount  of  an  ounce  and  an  ounce  and  a  half  daily,  and  also  nitre, 
in  a  dose  increased  from  one  to  two  scruples.  This  treatment 
proved  so  successful,  that  every  sign  of  effusion  disappeared  in 
the  course  of  eight  days.  During  the  present  year,  the  same 
patient  came  once  more  into  the  hospital,  affected  with  acute 
pleuro-pneumonia  of  the  right  side,  and  died  there.  On  examin- 
ation after  death,  the  left  lung  was  found  perfectly  free  from 
adhesions.  2.  The  second  case  was  that  of  a  lady,  whom  I  at- 
tended two  years  ago  with  MM.  Recamier  and  Moreau  de  la 
Sarthe.  She  had  been  affected  for  several  years  with  hypertrophy 
and  dilatation  of  the  heart ;  and  during  the  last  months  of  her 
life,  she  presented  all  the  signs  of  an  effusion  into  the  pleura  on 
the  right  side,  and  particularly  a  constant  and  very  distinct 
segophony  at  the  roots  of  the  lung,  around  the  whole  lower  angle 
of  the  scapula,  occasionally  extending  to  the  axilla.  Upon  ex- 
amining the  body,  we  found  about  a  pint  and  a  half  of  a  perfectly 
limpid  serum,  occupying  the  lower  two  thirds  of  the  right  pleura, 
which  was  in  this  place  perfectly  healthy,  and  without  any  false 
membranes,  old  or  new.  Above  this,  the  pulmonary  and  costal 
pleura  were  united  by  means  of  a  plentiful  cellular  tissue,  which 
was  strong,  and  obviously  of  long  standing. 

Its  progress,  and  the  state  of  the  general  symptoms,  can  alone 
distinguish  this  disease  from  chronic  pleurisy.  There  are  cases, 
even,  when  the  distinction  between  the  two  diseases  is  difficult 
in  the  dead  body.  Whatever  may  be  the  difference,  both  in  the 
general  symptoms  and  the  organic  lesion,  between  a  case  of  hydro- 
thorax  and  an  acute  pleurisy  ;  or  between  a  case  of  ascites  from 
general  debility  or  organic  disease  of  the  heart  or  liver,  and  the 
same  disease  from  an  attack  of  peritonitis ;  or,  in  short,  whatever 
may  be  the  difference,  in  general,  between  a  dropsy  and  an  in- 
flammation,— there  can  be  no  doubt  that  these  two  affections,  so 
opposite  in  their  extreme  degrees,  are  nevertheless  often  very 
nearly  allied  in  their  slighter  shades.     We  frequently  find  amid 


520  IDIOPATHIC    HYDROTHORAX. 

the  serum  of  ascites  or  hydrothorax,  filaments  of  a  milk-white  or 
yellowish  color  and  semi-transparent,  formed  of  concrete  albu- 
men, almost  as  solid  as  false  membrane.  And  we  observe  analo- 
gous facts  in  other  diseases.  Thus,  for  instance,  it  is  not  always 
easy  to  distinguish  oedema  of  the  lungs  from  the  first  degree  of 
pneumonia.  Again,  we  frequently  observe  prevailing  at  the  same 
time,  erysipelas,  accompanied  by  a  greater  or  less  oedema  of  the 
neighboring  parts,  and  general  cedema  of  the  greater  part  of  the 
body  attended  merely  with  a  slight  erythema  ;  while  in  the  in- 
flammation of  serous,  mucous,  and  synovial  membranes,  a  copious 
serous  effusion  always  accompanies  the  extravasation  of  pus  whe- 
ther concrete  or  fluid  :  and  the  same  thing  is  frequently  observed 
in  the  inflammation  of  the  cellular  substance.  These  facts  tend 
to  explain  the  admission  made,  by  certain  authors,  of  inflam- 
matory dropsies,  and  the  fact  of  blood-letting  being  occasionally 
beneficial  in  dropsy,  and  injurious  in  diseases  truly  inflammatory.* 
This  last  is  especially  the  case  when  the  inflammation  is  of  a 
chronic  kind,  or  originates  in  a  cause  which  is  not  within  the  con- 
trol of  antiphlogistic  treatment.! 

The  causes  of  diseases  are  unfortunately,  for  the  most  part, 
beyond  our  reach,  yet  we  learn  from  daily  experience,  that  the 
particular  character  of  the  causes,  occasions  greater  differences 
among  diseases  (especially  as  regards  their  cure)  than  the  nature 
and  kind  of  the  organic  lesions.  Many  cases  of  pleurisy  and 
peritonitis  are  equally  untractable  by  venesection,  as  a  bubo  or 
venereal  ulcer,  or  as  the  local  inflammation  of  gout,  or  that  which 
precedes  hospital  gangrene. — I  am  far  from  calling  in  question 
the  utility  of  the  study  of  diseases  according  to  their  anatomical 
characters.     This  study  has,  indeed,  been  my   constant  occupa- 

*  The  great  rarity  of  the  true  hydrothorax  ought  to  make  us  cautious  how  we 
give  this  name  to  so  many  affections  as  we  are  accustomed  to  do  ;  and  the  un- 
doubted fact  of  a  serous  effusion  being  an  almost  uniform  attendant  on  the  in- 
flammation of  serous  membranes,  ought  to  make  us  slow  to  trust  to  mere  diuret- 
ics and  other  similar  remedies  in  cases  wherein  we  have  strong  reason  for  sus- 
pecting dropsical  effusion,  especially  in  the  chest.  The  now  very  generally 
allowed  connexion  between  dropsy  and  inflammation,  mentioned  by  our  author 
in  many  parts  of  his  treatise,  is  still  much  better  understood  in  England  than 
France.  For  ample  and  most  valuable  illustrations  of  this  doctrine,  I  refer  the 
reader  to  the  well-known  works  of  Blackall,  Parry,  Crampton,  and  Ayre,  and 
and  to  the  various  articles  in  the  Cyclopaedia  of  Pract.  Med.  by  Dr.  Darwell,  on 
the  subject  of  Dropsy. —  Transl. 

t  No  doubt  the  inflammation  of  a  serous  membrane  may  in  the  end,  bring  on 
the  exhalation  of  a  liquid  which,  by  its  limpidity  and  transparence,  differs  from 
that  commonly  produced  by  a  state  of  inflammation.  But  those  cases  in  which 
dropsy  succeeds  to  inflammation,  must  be  distinguished  from  those  where  the 
dropsy  results  from  a  plethoric  state  of  the  system.  These  are  the  dropsies 
called  active,  and  to  remedy  which,  bleeding  has  been  employed  with  advantage 
from  the  most  ancient  periods.  There  may  be  dropsies  connected  with  a  gene- 
ral state  of  hyperemia,  as  there  are  dropsies  connected  with  anemia.  In  these 
two  cases,  we  must  not  look  for  the  causes  in  the  pathological  condition  of  the 
organs  themselves. — Aniral. 


SYMPTOMATIC    HYDROTHORAX. 


521 


tion,  and  this  work  is  entirely  devoted  to  the  exposition  of  its 
results.  I  am  of  opinion  that  this  study  can  alone  constitute  the 
basis  of  all  positive  knowledge  in  medicine ;  and  that  we  can 
never  lose  sight  of  it  in  our  etiological  researches,  without  risk  of 
pursuing  illusions,  and  of  creating  phantoms  in  order  to  combat 
them.  It  is  not  given  to  all  men  to  reach,  like  Sydenham,  that 
high  degree  of  medical  tact,  whereby  we  can  safely  disregard  the 
details  of  diagnosis  and  direct  our  practice  by  the  indications 
only :  and  I  believe  that  this  great  man  would  have  been  still 
more  distinguished  as  a  practitioner,  could  he  have  applied  to  the 
morbid  anatomy  of  diseases,  the  same  talent  for  observation, 
which  he  showed  in  the  study  of  symptoms  and  in  the  application 
of  remedies.  At  the  same  time,  I  consider  it  no  less  dangerous 
to  bestow  such  an  exclusive  attention  on  the  local  affections,  as  to 
make  us  lose  sight  of  the  causes  whence  they  spring.  The  ne- 
cessary consequence  of  this  mode  of  proceeding,  is  to  make  us 
frequently  mistake  the  effect  for  the  cause,  and  to  commit  the  still 
more  serious  error  of  considering  as  identical,  and  of  treating  in 
the  same  manner,  all  diseases  which  present  the  same  anatomical 
characters.  This  error,  which  appears  to  be  thatof  some  prac- 
titioners of  the  present  time,  is  to  me  quite  inconceivable.  It 
may  perhaps  be  the  consequence  of  a  slight  superficial  attention 
to  the  study  of  morbid  anatomy  ;  but  I  consider  it  as  impossible, 
that  any  person  of  good  sense,  who  follows  up  this  study  care- 
fully and  without  systematic  prejudices,  can  continue  long  under 
such  a  delusion. 

Sect.  II. —  Of  Symptomatic  Hydrothorax. 

The  symptomatic  hydrothorax  is  as  frequent  as  the  idiopathic 
is  rare.  The  symptomatic  dropsy  may  accompany  almost  every 
disease,  acute  or  chronic,  general  or  local :  its  presence  almost 
always  announces  their  approaching  and  fatal  termination,  and 
often  precedes  this  only  a  few  moments.  It  is  not  perhaps  more 
frequent  in  cases  of  ascites  and  general  anasarca  than  in  other  dis- 
eases. It  is  most  commonly  met  with  in  persons  who  have  died 
of  acute  fever,  disease  of  the  heart,  or  tubercles  or  cancer  of 
different  organs.  Its  symptoms,  which  are  in  every  respect  like 
those  of  the  idiopathic  disease,  do  not,  in  general,  make  their 
appearance  but  a  few  days,  or  even  hours,  before  death.  Nothing 
is  more  uncommon,  even  in  organic  affections  of  the  liver  and 
heart,  attended  by  ascites  and  general  anasarca, "than  to  meet  with 
the  signs  of  hydrothorax  so  long  as  eight  days  before  death.  We 
may  even  consider  this  disease  as  peculiar  to  the  moribund.* 

"  I  rannot  at  all  subscribe  to  this  opinion  of  our  author,  as  I  have  repeatedly 
treated  cases  of  symptomatic   hydrothorax  which  existed  for  months,  and  even 

66 


522  SYMPTOMATIC  HYDROTHORAX. 

When  the  effusion  takes  place  on  both  sides  of  the  chest,  it  pro- 
duces a  very  painful  suffocation.  Sometimes,  however,  we  find  a 
considerable  effusion  on  both  sides,  in  cases  where  there  had  been 
no  very  marked  dyspnoea  before  death.  Might  not  the  effusion 
in  such  cases  take  place  in  the  very  moment  of  dissolution, — or 
even  after  death  ?  We  know  that  the  functions  of  the  capillary 
system  do  not  cease  immediately  after  death.  I  have  sometimes 
found  more  than  a  pound  of  serum  in  the  cavity  of  the  pleura, 
ia  persons  who  exhibited  no  sign  of  effusion  even  a  quarter  of  an 
hour  before  death  ;*  and  twice  or  thrice,  in  cases  of  pleurisy,  I 
have  hardly  found  one  or  two  ounces  of  serosity,  although  sego- 
phony  had  been  distinct  during  life.  Is  it  not  probable,  in  the 
first  of  these  cases,  that  the  effusion  took  place  after  death ;  and 

years  before  death;  and  the  true  nature  of  which  was  not  merely  demonstrated 
by  the  physical  signs,  and   by  the  relief  afforded  by  diuretics,  but  by  the  state  of' 
the  membranes  after  death. 

In  regard  to  the  symptoms  of  hydrothorax,  although  it  may  be  strictly  true, 
as  Laennec  observes,  that  the  chief  and  almost  the  only  one  is  dyspnoea,  still 
there  are  commonly  present  others  which  convey  to  the  experienced  practition- 
er, even  although  not  an  auscultator,  a  pretty  strong  assurance  of  the  true  na- 
ture of  the  disease.  I  will  extract  a  few  passages  from  Dr.  Darwall's  paper 
(Cyc.  of  Pract.  Med.  vol.  ii.  p.  519,  520.)  illustrative  of  the  point.  "  To  what- 
ever affection  of  the  thoracic  viscera  hydrothorax  is  to  be  traced,  the  earliest 
symptom  of  effusion  is  an  cedematous  state  of  the  eyelids,  occurring  chiefly  in 
the  morning.  This  is  sometimes  so  little  remarkable,  that  it  escapes  attention 
until  inquiry  be  made  by  the  medical  attendant ;  and  often  it  is  only  remem- 
bered when  the  feet  and  ancles  have  been  observed  to  swell  in  the  evening. 
The  progress  of  the  disease  from  this  point  is  exceedingly  variable,  and  this  va- 
riableness seems  to  depend  much  upon  the  nature  of  the  original  affections.  In 
diseases  of  the  heart  the  early  progress  is  usually  slow,  the  breathing  being 
manifestly  more  difficult  than  before  the  external  oedema  was  perceived,  but  for 
some  time  not  aggravated  in  any  remarkable  degree.  Gradually,  however,  the  ex- 
ternal oedema  increases,  and, pari  passu,  the  thoracic  oppression,  the  difficulty  of 
lying  down,  the  dyspnoea,  &c.  become  more  distressing.  At  first,  probably,  little 
attention  is  paid  to  the  difficulty  of  assuming  the  recumbent  posture,  the  patient . 
satisfying  himself  with  having  his  head  raised  by  more  pillows.  The  necessity  of 
having  additional  pillows  continually  augments,  till  at  length  perfect  orthopnoea  is 
established,  and  he  is  only  abje  to  sleep  in  a  chair.  The  dyspnoea  undergoes  also 
at  times  very  severe  exacerbations,  the.  cause  of  which  is  not  very  readily  ascer- 
tainable  The  duration  of  this  state  varies  considerably  in  different  individ- 
uals, sometimes  lasting  for  weeks  without  any  alleviation  of  symptoms,  sometimes 
admitting  of  great  relief  by  medicine,  and  intervals  of  almost  perfect  ease  ;  at 
other  times  its  progress  is  extremely  rapid,  a  few  days  only  intervening  between 

the  first  symptoms  of  effusion   and  dissolution What  we  have  said  refers 

to  hydrothorax  from  disease  of  the  heart ;  when  it  succeeds  to  bronchitis  or 
pneumonia  the  progress  is  somewhat  different.  The  palpitations  and  other  car- 
daic  symptoms  are  usually  wanting,  and  there  is  nothing  more  manifested  than 
increased  dyspnoea.  Previously  to  this  becoming  very  marked,  however,  the 
face  and  feet  swell  as  in  the  former  instance  ;  the  patient  then  requires  the  head 
and  shoulders  to  be  raised  ;  and  at  length,  as  in  the  former  case,  he  is  unable  to 
lie  down  at  all.  In  th«se  cases  the  termination  is  seldom  so  sudden  as  when 
the  heart  is  diseased,  neither  does  the  countenance  exhibit  in  the  same  degree 
the  purple  and  livid  appearance:"—  Transl. 

I  think  it  very  doubtful  whether  so  huge  a  quantity  of  serosity  as  stated  by 
Laennec  can  be  separated  from  the  blood  after  death.  The  fact  Wleast  requires 
re-examination. — Andral. 


SYMPTOMATIC  HYDROTHORAX. 


523 


in  the  second,  on  the  contrary,  that  a  part  of  the  effused  fluid 
was  absorbed  in  the  mortal  agony,  or  even  after  death  ?*  The 
quantity  of  serum  effused  varies  from  a  few  ounces  to  one  or  two 
pints.  It  is  commonly  colorless  or  yellowish,  sometimes  tawny, 
reddish,  or  even  bloody. 

Considering  the  infrequency  of  true  hydrothorax,  it  is  hardly 
necessary  to  say  any  thing  of  its  treatment.  I  would  only  observe 
that  it  would  be  wrong  to  consider  the  disease  as  incurable  merely 
because  it  was  complicated  with  disease  of  the  heart.f  I  noticed 
above,  an  example  of  this  kind,  in  which  the  treatment  was 
rapidly  successful.  Diuretics  and  purgatives  are  the  chief  means. 
I  shall  not  repeat  what  I  formerly  stated  respecting  their  employ- 
ment in  thoracic  effusions,  as  almost  every  thing  recommended 
for  the  cure  of  the  chronic  pleurisy  is  applicable  to  that  of  hydro- 
thorax.  The  discharge  of  the  fluid  by  an  operation  would  seem 
to  afford  more  chances  of  success  in  hydrothorax  than  in  pleurisy, 
owing  to  the  freedom  of  the  lung  in  the  former  disease.! 

*  Some  of  my  readers,  I  suspect,  will  be  more  ready  to  believe  that  mediate 
auscultation,  in  these  cases,  gave  a  false  indication  of  the  state  of  the  parts  within 
the  chest  before  death  :  but  it  is  evidently  impossible  to  determine  the  point  one 
way  or  other. — Transl. 

t  Too  much  attention  cannot  be  directed  to  the  important  fact  here  mentioned 
by  Laennec.  In  fact,  it  is  very  common  to  see  a  dropsy  which  depends  on  an 
affection  of  the  heart,  disappear  entirely  after  haying  reached  a  very  high 
degree.  Nothing  more  is  necessary  to  produce  this  than  a  more  free  cir- 
culation through  the  heart  under  the  influence  of  repose  and  a  little  blood- 
letting. I  have  thus  seen  individuals  in  whom  a  dropsy  resulting  from  aneurism 
of  the  heart,  has  been  dissipated  seven  or  eight  times,  and  yet  each  time  there 
was  anasarca  to  a  high  degree,  and  very  manifest  ascites.  But  as  the  dropsy  is 
repeated,  the  probability  of  its  dissipation  becomes  less,  and  at  length  comes  on 
one  tlfat  cannot  be  removed.  It  is  further  to  be  remarked,  that  the  bleedings 
which  by  giving  altogether  mechanically,  more  liberty  to  the  circulation,  had 
exerted  a  powerful  indirect  influence  upon  .the  earlier  dropsies,  have  much  less 
effect  on  those  which  follow,  and  finally  become  of  no  use,  as  the  serous  effu- 
sions form  again. 

All  symptomatic  dropsies  are  not  to  be  dissipated  like  those  arising  from 
organic  affection  of  the  heart.  For  instance,  ascites  which  depends  on  a 
scfrrhus  of  the  liver,  is  commonly  slow  of  growth.  It  may  remain  more  or 
less  stationary,  but  when  once  it  has  appeared,  there  is  no  getting  rid  of  it. 

Dropsies  connected  with  affections  of  the  kidneys,  run  a  different  course  from 
the  preceding.  These  are  remarkable  for  coming  and  going  in  a  certain  manner, 
attacking  in  turn  the  most  different  parts  and  observing  no  uniform  course  in 
their  development,  like  those  arising  from  an  obstruction  in  the  venous  circula- 
tion of  the  heart  or  other  parts. — Andral. 

%  Symptomatic  hydrothorax  is  a  very  common  affection,  and  is  more  under  the 
control  of  medicine  than  many  less  important  diseases.  Indeed,  digitalis,  partic- 
ularly the  infusion  in  large  doses,  is  almost  a  specific  in  removing  the  fluid,  at 
least  for  a  time.  Dropsy  of  the  chest  frequently  accompanies  organic  disease  of 
the  heart ;  but  still  more  frequently,  perhaps,  is  the  latter  disease,  when,  unatten- 
ded by  any  effusion  into  the  pleura,  mistaken  for  the  former.  In  cases  of  this 
kind  the  stethoscope  is  of  great  use  in  directing  the  treatment ;  as  the  means  so 
successful  in  relieving  the  dropsical  affection,  are,  at  best,  useless  in  the  lesions 
of  the  heart.  Dr.  Maclean's  work  on  hydrothorax  is  well  deserving  the  atten- 
tion of  practitioners,  as  illustrating  the  power  of  digitalis  in  this  disease,  although 


524  BLOOD    IN    THE    PLEURA. 


CHAPTER  III. 


OF    BLOOD    EFFUSED    INTO    THE    CAVITY    OF    THE    PLEURA. 

Penetrating  wounds,  or  even  a  severe  contusion  of  the  chest, 
may  produce  an  effusion  of  blood  into  the  cavity  of  the  pleura. 

it  abounds  with  grievous  errors  in  pathology  and  diagnosis-  These  mistakes 
were,  perhaps,  pardonable  at  the  time  he  wrote  ;  in  the  present  state  of  our  knowl- 
edge they  could  hardly  be  committed  ;  certainly  if  committed,  they  would  be  now 
unpardonable. 

The  best  form  of  administering  digitalis  is  that  of  infusion,  in  doses  of  half 
an  ounce  every  eight  or  six  hours,  and  continued  until  it  has  increased  the  flow 
of  urine,  or  otherwise  manifested  its  specific  effects  upon  the  pulse  or  general 
system.  This  remedy  is  most  effective  in  the  asthenic  diathesis,  where  there  is 
much  debility,  with  pallid  skin  and  feeble  pulse.  The  diuretic  effect  of  digita- 
lis in  such  cases,  is  often  increased  by  combination  with  opium,  and  I  have  been 
usually  in  the  habit  of  conjoining  with  it  the  carbonate  of  potass  and  nitrous 
aether  as  practised  by  Dr.  Maclean.  If  the  hydrothorax  supervenes  to  disease 
of  the  heart,  while  there  still  exists  a  good  deal  of  power  in  the  system,  vene- 
section is  almost  always  proper;  and,  in  such  cases,  drastic  purgatives,  and  es- 
pecially elaterium,  often  produce  most  striking  relief.  When  the  elaterium  is 
found  to  act  beneficially,  it  should  be  repeated  every  two  or  three  days,  if  the 
strength  of  the  system  supports  its  action.  When  the  state  of  debility  is  great, 
we  must  either  combine  with  our  diuretics,  or  immediafelv  follow  them  up  by 
tonics,  particularly  the  milder  preparations  of  steel,  as  the  ferrum  tartarizatum 
or  the  hydriodate  of  iron.  In  the  agonizing  paroxysms  of  dyspnoea  in  the  last 
stage,  art  is  nearly  powerless  in  ministering  relief:  our  only  hope  of  even  tem- 
porary ease,  is  in  large  and  repeated  doses  of  opium,  particularly  the  black  drop 
of  Battley's  sedative,  not  regulated  by  times  or  quantities,  but  by  their  effects: 
with  these  we  commonly  combine  aether,  and  probably  not  without  reason. 

In  regard  to  the  operation  of  paracentesis,  which  Laennec  seems  to  regard 
somewhat  favorably,  1  believe  the  cases  of  hydrothorax  are  extremejy  few 
where  it  is  advisable  or  even  justifiable.  The  very  circumstance  of  the  effusion 
being  generally  present  in  both  sides  at  the  same  time,  is  a  strong  objection  : 
and  the  assured  brevity  of  the  relief  is  still  stronger  :  yet  when  the  disease  is 
extreme,  and  we  have  good  ground  for  believing  that  the  chief  part  of  this  de- 
pends more  on  the  effusion  than  on  the  organic  disease,  and  particularly  if  the 
fluid  is  entirely  or  chiefly  confined  to  one  sac  of  the  pleura,  I  do  not  think  we 
ought  to  be  deterred  from  affording  even  the  equivocal  relief  offered  by  the  ope- 
ration. Out  of  23  cases  of  effusion  into  the  chest,  in  which  the  operation  of  pa- 
racentesis was  performed  under  the  directions  of  Dr.  Thomas  Davies,  of  London, 
11  were  simple  empyema,  9  pneumothorax  with  effusion,  and  3  hydrothorax  :  of 
the  first,  8  recovered  ;  while  of  the  latter,  all  died.  It  is  proper  to  state,  how- 
ever, that  the  three  patients  with  hydrothorax  (all  from  disease  of  the  heart) 
were  relieved  by  the  operation  for  a  considerable  time.  (Cyc.  of  Prac.  Med.  vol . 
ii.  p.  43.) — Transl. 

LITERATURE  OF  HYDROTHORAX. 

1766.  Bouillet,  (J.  et  J.  H.  N.)  Obs.  sur  l'anasarque,  les  hydropisies  de  poitrine, 

•  &c.     Ber.  12mo. 
1790.  Haering,  (P.  P.)     De  hydrothorace.     Lips.  4to.     Id.  Abhandl.  von  der 

brustwassermcht.     Neueste  Samml.     Lips.  1794.  8vo. 
1795.  Gutherlet,  (J.  C.)     De  signis  hydropis  pectoris.     Wurtzb.  8vo. 
1799.  Chardel,  (F.)  Obs.  sur  l'hydropsie  de  poitrine,  &c.     Par.  8vo. 
1802.  Gerard,  (F.  M.)  Essai  sur  I'hydrothorax.     Par.  8vo. 


BLOOD    IN    THE    PLEURA. 


525 


The  same  thing  takes  place  in  certain  cases  of  disease,  and  may 
follow  the  rupture  of  an  aortic  aneurism.     In  some  cases,  also, 
there  is  no  doubt  that  a  very  copious  exhalation  of  blood  may 
take  place  spontaneously,  without  any  solution  of  continuity  or 
external  violence.     I   do  not  here  allude  to  those  effusions  which 
accompany  the  hemorrhagic  pleurisy,  or  which  sometimes  attend 
the  formation  of  blood-vessels  in  the  false  membranes,  or  which 
confer  on  certain  other  effusions  a  sanguineous  tint  merely  ; — but 
to  a  primary  and  idiopathic  effusion  of  blood,  analogous  to  the 
haemorrhages,  active  or  passive,  of  other  organs.     This  case  is 
doubtless  very  rare  ;  yet  some  examples  can  bear  no  other  ex- 
planation.    These  various  cases  constitute  what  has  been  impro- 
perly called  sanguineous  empyema.     The  most  common  of  these 
is,  unquestionably  that  which  occurs  in  the  hemorrhagic  pleurisy  ; 
and  almost  all  those  which  I  have  seen  become  the  subject  of 
operation  have  been  of  this  kind.     The  extravasations  of  blood 
produced  by  a  violent  contusion  are  in  general  easily  dispersed ; 
and  those  which  are  the  consequence  of  a  wound,  are  discharged 
by  the  wound  itself.     The  most  dangerous  species  is  the  sponta- 
neous, inasmuch  as,  being.usually  the  effect  of  a  general  hsemor- 
rhagic  diathesis,  the  removal  of  it,  however  affected,  will,  in  all 
probability,  be  followed  by  a  similar  effusion  in  some  other  place. 
Blood  effused  into  the  cavity  of  the  pleura  may  be  absorbed  as 
readily  as  when  thrown  into  the  cellular  substance  in  consequence 
of  a  blow  ;  and  we  know  that  enormous  extravasations  of  this  sort 
are  frequently  re-absorbed  in  a  few  weeks,  or  even  in  a  few  days. 
When  absorption  does  not  take  place  quickly,  the  blood  is  some- 
times decomposed,  and  an  aeriform  fluid  is  disengaged,  producing 
particular  symptoms,  as  we  shall  see  more  particularly  in  the 
chapter  on  pneumothorax. 

The  effusion  of  blood  into  the  pleura  affords  the  same  results 
from  percussion  and  mediate  auscultation  as  other  liquid  extra- 
vasations into  the  same  cavity.  I  shall  not,  therefore,  repeat  what 
was  formerly  stated  on  this  subject.  In  the  case  where  the  effused 
blood  should  be  entirely  or  almost  entirely  coagulated,  I  presume 

1803.  Lerousc,  (A.  H.)  Recherches  sur  la  Paracenthese  dans  les  Hydropisies  de 

poitrine.     Par.  8vo. 
1807.  Hamilton,  (W.,  M.D.)   Obs.  on  Digitalis  in  Dropsy  of  the  Chest,  &c. 

Lond.  8vo. 
1810.  Maclean,  (L.,  M.D.)  An  Enquiry  into   the   nature,  &c.  of  Hydrothorax. 

Sudbury.  8vo. 
1815.  Romerus,  (F.)  Obs.  exper.  confirmata  pro  hydrope  pectoris,  &c.  Par.  8vo. 
1818.  Itard.     Diet,  des  Sc.  Med.     (Art.  Hydrothorax,)  i.  22.     Par. 
1822.  Conte,  (J.  B.)  De  l'hydropisie  de  poitrine,  &c.     Par.  (2nd  ed.)  8vo. 
1824.  Rayer.     Diet,  de  Med.  (Art.  Hydrothorax,)  t.  11.     Par. 
1833.  Bouillaud.     Diet,  de  Med.  et  de  Chir.     (Art.  Hydrothorax.)    Par. 

1833.  Darwell.     Cyc.  of  Pract.  Med.  (Art.  Hydrothorax,)  vol.  ii.     Lond. 

1834.  Copland.     Diet,  of  Pract.  Med.  (Art.  Dropsy  of  the  Chest.)     Lond. 

Morgagni,  Stoll,  De  Haen,  Cullen,  Burserius,  Frank,  Good. 


52G  PNEUMOTHORAX. 

that  ccqophony  would  not  exist ;  since  the  transmission  of  the 
voice  through  a  fluid  appears  one  of  the  most  essential  conditions 
for  the  production  of  this  phenomenon. 

Treatment. — I  shall  not  here  repeat  what  was  formerly  said  of 
the  hemorrhagic  pleurisy.  The  effusion  of  blood  produced  by 
a  severe  contusion  of  the  chest,  or  the  fracture  of  a  rib,  requires, 
in  general,  the  employment  of  blood-letting  in  the  first  instance, 
to  relieve  the  dyspnoea  and  moderate  the  succeeding  inflammation. 
Diuretics  and  slight  purgatives,  given  from  time  to  time,  are  then 
the  best  measures  for  promoting  the  absorption  of  the  blood.  In 
the  effusions  occasioned  by  a  penetrating  wound  involving  the 
vessels  of  the  lungs,  the  most  rational  indication  is  to  confine  the 
blood  within  the  chest,  so  as  to  make  it  compress  the  lung  and 
thereby  check  the  haemorrhage  if  possible :  the  absorption  of  the 
blood  afterwards,  will  not  be  more  difficult  than  in  the  preceding 
instance.  The  spontaneous  effusion  is  unquestionably  the  least 
under  the  control  of  art,  being  always  the  consequence  of  a  hae- 
morrhagic  diathesis,  which  is  got  the  better  of  with  much  difficul- 
ty. This  case  is,  however,  extremely  rare :  and,  moreover,  almost 
all  that  was  formerly  stated  respecting  the  hemorrhagic  pleurisy 
is  applicable  to  it. 


CHAPTER  IV. 


OF     PNEUMOTHORAX,     OR     THE     ACCUMULATION     OF      AIR     IN     THE 
CAVITY    OF    THE    CHEST. 

Sect.    I. — Anatomical    Characters  and    Varieties   of    Pneu- 
mothorax. 

0 

Occasionally  we  find  aeriform  fluids  in  the  cavity  of  the  pleura. 
These  are  sometimes  without  smell,  more  commonly  fetid,  and  of 
a  fetor  resembling  that  of  sulphuretted  hydrogen  gas.  These 
fluids  are  sometimes  in  such  quantity  as  very  forcibly  to  com- 
press the  lung,  and  to  distend  the  thoracic  parietes  in  a  very 
sensible  manner.  In  this  case  the  ribs  are  found  more  or  less 
separated, — and  the  diaphragm  projects  into  the  cavity  of  the 
abdomen :  when  the  disease  exists  on  the  left  side  of  the  chest, 
the  muscle  is  found  considerably  prominent  downward  ;  and  when 
it  is  in  the  right  side  the  liver  is  thrust  below  the  margin  of  the 
ribs.  Although  this  affection  cannot  be  said  to  be  of  excessive 
rarity,  it  has  hitherto  been  but  little  noticed  by  medical  men. 
All  that  we  find  respecting  it  in  practical  writers,  are  a  few  ex- 


PNEUMOTHORAX. 


527 


amples  ycry  imperfectly  described  ;  and,  in  general,  we  know  it 
merely  from  the  casual  observations  of  anatomists  and  surgeons, 
who  have  occasionally  noticed  the  escape  of  air  in  opening  the 
chest  after  death,  or  in  performing  the  operation  of  empyema.* 
There  exists  no  special  memoir  on  this  subject,  to  the  best  of  my 
knowledge,  but  an  inaugural  dissertation  of  twenty  pages,  by 
M.  Itard,  at  present  physician  to  the  institution  for  the  deaf  and 
dumb.f  The  disease  is.  named  by  M.  Itard,  Pneumothorax. 
He  details  five  cases  of  it,  three  cases  of  which  are  original,  one 
extracted  from  Selle,  and  the  fifth  furnished  by  M.  Bayle.  In 
these  the  aerial  effusion  co-existed  with  phthisis  and  chronic  pleu- 
risy ;  and  in  all  of  them  the  lungs  of  the  affected  side  were  com- 
pressed into  a  small  compass  towards  their  roots.  The  fluid  was 
more  or  less  fetid.  The  cavity  of  the  pleura  was  invested  by  a 
false  puriform  membrane,  at  least  in  the  instances  noticed  with 
any  degree  of  detail,  and  contained  a  few  spoonsful  of  pus.  The 
author  of  this  memoir,  in  conformity  with  the  then  established 
notions,  considers  the  pneumothorax  as  an  affection  always  con- 
sequent to  and  depending  on  a  latent  phthisis  ;  and  that  its  ex- 
citing cause  is  "  the  decay  of  the  lungs  by  means  of  a  chronic 
suppuration,  together  with  the  partial  absorption  and  decom- 
position of  the  pus  owing  to  its  long  stagnation  in  a  confined 
cavity."  We  have  already  seen  that  this  consumption  of  the 
lung  (pulmones  assumpti  of  Lieutaud,)  is  not  owing  to  the  de- 
struction of  that  viscus  by  suppuration,  but  that  the  collection  of 
purulent  matter  is  the  cause  and  not  the  effect  of  the  diminished 
size  of  the  lungs.  This  fact,  which  I  believe  M.  Corvisart  was 
the  first  to  demonstrate  in  his  clinical  lectures,  is  now  considered 
as  unquestionable  by  every  one  well  acquainted  with  morbid 
anatomy.  In  former  pages  we  have  ourselves  shown  that  the 
lungs  may  be  reduced  to  a  very  small  volume  by  purulent  or 
watery  effusions,  without  containing  tubercles,  or  showing  any 
mark  of  suppuration.  All  the  cases  of  M.  Itard,  then,  are  to  be 
considered  as  pneumothorax  consequent  to  a  latent  pleurisy, 
which  co-existed  with  the  phthisis,  and  in  which  the  greater  part 
of  the  effused  liquid  had  been  absorbed. 

It  is  sufficiency  probable  that,  in  these  cases,  the  gas  was  the 
product  of  the  decomposition  of  some  portion  of  the  effused  albu- 
minous and  puriform  matter :  the  character  of  its  smell  leads  to 
this  opinion.     This  species  of  pneumothorax  is  pretty  frequent.^ 

+  Vide  Riolan,  Enchirid.  Anat.  lib.  iii.  cap.  ii. — Pouteau,  CEuv.  Post.  t.  iii. 

t  Dissertat.  sur  le  Pneumothorax,  &c.  Paris,  1803. 

i  The  subsequent  more  extended  experience  of  pathologists  render  this  opin- 
ion of  Itard  and  Laennec  respecting  the  source  of  the  air  in  these  and  other 
similar  cases,  more  than  problematical.  Indeed  there  can,  I  think,  be  little  doubt 
that  the  air  in  M.  Itard's  cases  originated  in  a  fistulous  communication  with  the 
bronchi,  although   this  was  not  detected  on  examination.      I  am  even  disposed 


528  PNEUMOTHORAX. 

There  are  several  other  varieties  sufficiently  distinct.  .1  have 
several  times  discovered  this  affection  co-existing  with  a  con- 
siderable sero-purulent  effusion  of  the  pleura,  and  a  communi- 
cation between  this  cavity  and  the  bronchi,  owing  to  the  rupture 
of  a  vomica,  or  softened  tubercle,  simultaneously  into  the  bronchi 
and  pleura.  I  consider  this  species  as  the  commonest  of  all ;  at 
least,  I  have  met  with  it  most  frequently.*  In  this  case  it  is 
reasonable  to  believe  the  air  contained  in  the  cavity  of  the 
pleura  to  be  simply  the  atmospheric  air  conveyed  thither  by  the 
bronchi.  I  shall  subjoin  several  remarkable  instances  of  this 
variety.  It  is  possible  that,  in  this  case,  the  introduction  of  the  air 
into  the  pleura  may  excite  inflammation  of  that  membrane,  and 
that,  consequently,  the  pleurisy  may  be  the  effect  of.  its  presence, 
and  not  the  cause,  as  in  the  instances  given  by  M.  Itard.  It  is, 
however,  also  possible,  that  a  vomica  may  burst  into  this  cavity 
without  at  the  same  time  communicating  with  the  bronchi,  and 
may  thus  excite  a  pleurisy,  and  consequent  pneumothorax, 
through  the  decomposition  of  the  pleuritic  fluids.  This  case 
comes  under  the  same  head  as  those  of  Itard,  with  this  difference, 
that  the  original  effusion  is  here  considerable.  Pneumothorax 
may  also  be  conjoined  with  hydrothorax  ;  and  indeed  the  phe- 
nomena of  certain  cases  that  have  occurred  demonstrate  its  exist- 
ence. It  is,  no  doubt,  probable  that  most  of  the  supposed  cases 
of  this  kind  have  been  truly  pleuritic  effusions,  mistaken  for  the 
simple  serous  exhalation ;  but  M.  Bayle  gives  one  incontestable 
instance  of  this  sort,  in  a  person  where  there  was  found  a  small 
portion  of  serum  and  a  great  quantity  of  air  in  the  pleura  .f  I 
have  myself  frequently  observed  a  certain  quantity  of  air  together 

to  doubt,  with  Dr.  Houghton  and  other  modern  pathologists,  if  pneumothorax,  is 
ever  produced  by  the  decomposition  of  a  pleuritic  effusion.  "  It  may  be  laid 
down  as  proved  (says  Dr.  Houghton)  that  where  pneumothorax  exists,  the  air 
has  been  introduced  from  without ;  for  cases  of  an  opposite  description  are  so 
rare  that  they  must  be  considered  as  exceptions  to  the  rule." — {Cyc.  of  Pract. 
Med.  vol.  iii.  p.  452). —  Transl. 

*  "  This  species  of  the  affection,"  [that  is,  pneumothorax  from  the  bursting  of 
a  tubercular  abscess  into  the  pleura,]  says  Dr.  Houghton,  "  is  beyond  all  compari- 
son, more  frequent  than  all  others.  If  we  were  to  conclude  from  the  experi- 
ence of  the  medical  men  of  Dublin  who  have  given  most  attention  to  the  sub- 
ject, it  might  be  asserted  that  it  constitutes  fully  nine-tei»ths  of  the  cases  ol 
pneumothorax,  with  the  exception  of  the  trumatic  variety  ;  and  this,  or  even  a 
greater  proportion,  is  established  by  the  cases  found  in   medical   writings  since 

the  publication  of  Laennec's  work The  rupture  may  occur  in  any  of  the 

lobes  of  the  lung  ;  but  the  inferior  part  of  the  upper  lobe,  and  the  superior  part 
of  that  beneath  it,  is  the  place  where  it  has  been  mosh  usually  observed,  in  a 
great  majority  of  cases  it  has  been  found  to  happen  on  a  line  with  the  third  rib, 
posteriorly  about  the  costal  angle  and  just  under  the  reflection  of  the  false  mem- 
brane by  which  the  superior  lobe  is  so  generally  adherent.  But  it  may  happen 
at  any  part  of  the  pulmonary  substance."  (Cyc.  of  Pract.  Med.  vol.  iii.  p.  451, 
sq.) — Transl. 

f  Recherches  sur  la  Phthisie,  p.  176,  Obs.  xi. 


PNEUMOTHORAX.  0/iu 


with  the  serum,  in  the  symptomatic  hydrothorax,  supervening  just 
before  death. 

Pneumothorax  also  occurs  almost  always  when  a  gangrenous 
eschar  of  the  lungs  is  softened  and  evacuated  into  the  cavity  of 
the  pleura.  In  this  case  gas  is  evolved  during  the  chemical 
decomposition  of  such  matter;  and  this,  together  with  the  fluids 
effused  by  the  irritated  pleura,  compresses  the  lung,  and  dilates 
the  affected  side.  We  have  already  given  two  examples  (Cases 
XV.  and  XVII.)  of  this  species  of  pneumothorax.  Gangrene 
of  the  pleura,  also,  commonly  produces  the  same  effect.  A  case 
of  this  kind  will  be  subjoined.  The  same  results  follow  the 
decomposition  of  blood  effused  into  this  cavity.  On  examining 
the  body  of  a  man  that  died  after  an  illness  of  five  days,  Littre 
found  in  the  chest  two  pints  of  blood,  and  an  enormous  quantity 
of  air.  This  affection  may,  further,  be  produced  by  rupture  of 
the  pleura  of  the  lungs,  from  external  violence.  A  case  of  this 
kind  is  mentioned  by  Hewson.* 

It  is  likewise  probable  that  in  the  case  of  emphysema  of  the 
lungs,  with  rupture  of  some  of  the  air-cells  and  extravasation  of 
air  under  the  pleura,  this  membrane  may  sometimes  be  ruptured, 
and  the  disease  in  question  be  thus  formed.  I  saw  a  case  of  this 
kind  a  short  time  since.  It  seems  further  probable  that  in  the 
case  or  emphysema  of  the  lungs  with  rupture  of  the  air-cells  and 
extravasation  of  the  air  under  the  pleura,  this  membrane  may 
itself  be  ruptured  and  thereby  give  rise  to  pneumothorax.-  I 
think  I  have  met  with  such  a  case ;  but  as  the  note  I  made  of  it 
is  lost,  I  will  not  venture  to  assert  the  thing  as  positive.  Even 
in  the  acute  pleurisy  in  its  commencement,  and  without  any 
chemical  decomposition  of  the  effused  fluid,  there  may  co-exist 
a  gaseous  effusion ;  and  I  shall  detail  a  remarkable  example  of 
this  at  the  end  of  the  present  section.  Finally,  an  aeriform  fluid 
may  be  formed  in  the  cavity  of  the  chest,  without  there  being 
any  solution  of  continuity,  any  other  effusion,  or  any  perceptible 
change  of  structure  whatever.  I  have  often  perceived  the  escape 
of  an  inodorous  gas,  in  opening  the  thorax,  where  there  was  no 
perceptible  affection  of  the  pleura.  Sometimes,  indeed,  this 
membrane  appeared  to  be  drier  than  natural ;  and  I  remember 
one  case  in  which  it  was,  in  some  places,  almost  as  dry  as  parch- 
ment. Even  in  these  cases  a  rupture  of  the  pleura,  so  slight  as 
to  be  unperceived,  may  be  imagined  ;  but,  independently  of  the 
circumstance  that  such  rupture  cannot  well  be  supposed  without 
some  external  violence,  we  know  that  an  idiopathic  formation  or 
secretion  of  air  can  and  does  take  place  in  the  animal  system.  It 
is  thus  that  we  sometimes  find  air,  in  considerable  quantity,  in 

"   Med.  Obs.'and  Inq.  vol.  iii. 
67 


530  PNEUMOTHORAX. 

the  pericardium,  in  the  synovial,  capsules,  and  under  the  arachnoid 
in  cases  where  there  exists  no  other  effusion  within  these  mem- 
branes ;  we  find  the  same,  also,  though  more  rarely,  in  the  cavity 
of  the  peritoneum.  It  would  even  appear  that  air,  or  an  aeri- 
form fluid,  exists  naturally,  in  small  quantity,  in  the  cavity  of 
the  pleura.  At  least,  M.  Ribes  assures  me  that  he  has  found, 
in  opening  the  serous  cavities  of  dogs,  a  small  quantity  of  air 
constantly  to  escape.  This  may  probably,  however,  be  merely 
the  natural  serous  exhalation  in  a  state  of  vapor.* 

Whatever  be  the  nature  of  the  gas  contained  in  the  cavity  of 
the  pleura,  in  simple  pneumothorax,  we  can  conceive  that  it  may 
long  remain  there,  without  giving  rise  to  any  inflammatory  affec- 
tion of  the  pleura,  as  would  no  doubt  be  the  effect  of  atmospheric 
air  introduced  by  means  of  a  tuberculous  excavation  communi- 
cating .simultaneously  with  the  bronchi  and  pleura.f  In  fact, 
air  secreted  by  the  vessels  of  the  pleura,  must  be  in  some  sort 
annualized,  and,  therefore,  much  less  likely  to  irritate,  than  a 
body  so  thoroughly  extraneous  to  the  animal  system,  as  the  air 
of  the  atmosphere.  That  air  introduced  into  the  pleura  in  the 
manner  just  indicated,  is  not  always  productive  of  a  fatal  or  even 
severe  pleurisy,  is  proved  by  the  following  case,  which,  moreover, 
affords  a  good  example  of  a  disease  but  little  known  and  imper- 
fectly described  4 

Case  XXXV. — Simple  pneumothorax,  conjoined  with  latent 
phthisis. — A  man,  aged  sixty-five,  of  a  strong  constitution,  sub- 
ject for  two  years  to  a  cough  which  did  not  prevent  him  from 
following  his  business,  was  attacked  on  the  15th  October,  1816, 
with  violent  pains  in  the  abdomen,  and  died  the  same  night,  in 
the  Necker  Hospital. 

*  There  issti'l  another  mode  in  which  pneumothorax  originates,  viz.  from  the 
perforation  of  the  pleura  and  bronchi,  from  without  inwards,  that  is,  by  the  mat- 
ter of  an  empyema.  A  base  by  Dr.  Archer  (Trans.  Dub.  Assoc,  vol.  ii.),  and 
another  by  Dr.  Hawthorne  (Ed.  Journ.  vol.  xv.)  appear  to  he  of  this  kind.  It 
often  happens,  however,  that  the  matter  of  empyema  perforates  the  lung  and  is 
discharged  by  the  bronchi  without  the  supervention  of  pneumothorax. —  Trans!. 

i  The  air  contained  in  the  sac  of  the  pleura  in  pneumothorax  has  been  chem- 
ically examined  by  Dr.  Davy  and  Apjohn  (Phil.  Trans.  1824.— Dub.  Trims,  of 
Coll.  Phys.  vol.  v.)  and  has  been  found  to  he  atmospheric  air  slightly  modified. 
By  Dr.  Apjohn's  analysis  the  100  parts  consisted  of  carbonic  acid,  8  ;  oxygen.  10  ;, 
nitrogen.  82  ;  In  Dr.  Davy's  cases  the  gas  consisted  of  7  or  8  parts  of  Carbonic 
acid,  and  !I2  or  93  of  oxygen.  In  one  of  Louis's  cases  (Snr  In  Phthisic,  obs.  x. 
41)  the  gas  is  said  to  have  been  carbonic  acid,  but  no  positive  analysis  is  stated  to 
have  been  made. —  Transl. 

X  After  reading  Laennec's  learned  and  complete  enumeration  of  the  different 
species  of  pneumothorax, a  physician  little  conversant  with  researches  in  patho- 
logical anatomy  would  suppose  them  all  equally  common  or  nearly  so  ;  this, 
however,  is  not  the  fact  :  the  most  common  pneumothorax  is  that  occasioned  by 
Vhe  opening  of  a  tuberculous  excavation  into  the  pleura.  It  is  probable  that  this 
class  comprises  those  cases  observed  by .Bayle,  in  which  he  found  the  pleura 
filled  with  gas  in  individuals  who  at  the  same  time  had  pleurisy  and  pulmonary 
tubercles  on  the  side  where  the  gas  existed.— Jlfidral. 


PNEUMOTHORAX.  531 


After  death,  the  body,  though  emaciated,  still  retained  con- 
siderable muscularity.     The  right  side  of  the  chest  was  evidently 
larger  than  the  left,  and  yielded  a  louder  sound  on  percussion 
than  even  the  chest  of  a  healthy  person  usually  does.     The  left 
side    yielded  a  sound  comparatively  obscure    through    its   whole 
extent.     There  were   found  some   diseased  appearances  in   the 
brain.     On    penetrating  by  the    scalpel    the  right  cavity  of  the 
chest,  an  inodorous  gas  escaped,  and  in  large  quantity,  to  judge 
by  the   force  and   duration  of  the   sound   occasioned  by  its  exit. 
The   lung  on  this  side  was  somewhat  compressed  towards  its 
roots,  but   still  retained  three-fourths  of  its  natural  dimensions. 
The  side  of  the  chest  was  considerably  dilated,  and,  besides  the 
lung,  might  have  contained  about  two  pints  of  liquid, — the  quan- 
tity^ no  doubt,  of  gas  that  had  made  its  escape.     The  whole  of 
the  pleura    was    drier  than    usual,  and    rather  slightly  unctuous 
than   humid  ;  there    were   no   false  membranes  nor  any  effused 
fluid.     The  lung  adhered  to  the  costal  pleura  at  its  upper  lobe, 
by  means  of  cellular  layers  an  inch  in  length,  which  seemed  of 
no  very  ancient  date.     This  adhesion  was  attached  at  one  end  to 
a   species  of  cartilaginous   incrustation  of  the   size  of  the   palm 
of  the  hand,  which  adhered  closely  to  the  pleura  pulmonalis.     In 
detaching    the    cellular   adhesions    from    this    nbro-cartilaginous 
body,   there  remained  in   the  center  of  the  latter,  a  small  oval 
opening,   about  a  line  and  a   half  in  diameter,  which  communi- 
cated with  an  excavation  in  the  lung,  which  could  have  contained 
an  orange.     I  am  not  quite   certain   whether  the  oval   opening, 
above   mentioned,   existed  before,  or  was  formed  by  the  act  of 
detaching  the  lung  from   its  adhesions  ;  though  I  am  inclined  to 
consider  it  as   previously  existing.     The   excavation  was  nearly 
empty,  containing  only  about  a  spoonful  of  pus.     Its  parietes 
were    immediately  formed  by  the    pulmonary  tissue,    except  in 
that  space  answering  to  the  cartilaginous  incrustation,  where,  to 
the  extent  of  more  than  an  inch  square,  they  consisted  solely  of 
this  false  membrane.     There  were  many  tubercles,  in  different 
stages,  and  also  numerous  hard    melanose  tumors  in  different 
parts  of  the  lung.     The  left  lung  adhered  to  the  costal  pleura  in 
its  whole  extent.     It  also  contained  tubercles  and  melanose  tu- 
mors.    There  was,  likewise,  a  tuberculous  cavity,  of  consider- 
able size,  in  the  upper  lobe,  and  there  was  disease  in  the  large 
intestines. 

In  the  above  case  the  aeriform  effusion  into  the  right  side  of 
the  pleura,  may  with  equal  probability,  be  attributed  either  to 
the  rupture  of  the  tuberculous  excavation  existing  in  the  upper 
part  of  the  lung  into  the  bronchi  and  pleura  at  the  same  time, 
or  to  the  simple  exhalation  of  the  air  into  the  pleura.  The  former 
supposition  is  supported  by  the  fact  of  the  existence  of  the  open- 


532  P-NEHMOTIIORAX. 

ing  (if  indeed  such  did  exist)  at  the  summit  of  the  lung  and  by 
the  state  of  the  false  membranes,  particularly  their  thickness  at 
the  base  :  the  latter  is  rendered  more  probable  by  the  co-exist- 
ence of  air  in  the  pericardium,  a  circumstance  which  would  seem 
to  indicate  a  general  disposition  of  the  serous  membranes  to 
secrete  air ;  and  this  probability  is  heightened  by  the  doubt 
which  exists  as  to  whether  there  really  was  any  opening  into  the 
pleura. 

Sect.  II. — Of  the  Symptoms  and  Signs  of  Pneumothorax. 

The  symptoms  of  pneumothorax  are  very  obscure,  inasmuch 
as  they  may  belong  to  many  other  affections.  The  only  one 
which  is  pretty  constant  is  a  certain  degree  of  dyspnoea :  cough 
does  not  seem  necessarily  to  accompany  it.  Percussion  by  itself 
does  not  supply  any  certain  result.  When  the  accumulation  of 
air  is  very  considerable,  the  affected  side  yields  a  clearer  sound 
than  the  other ;  but  this  difference,  even  when  very  distinct,  so. 
far  from  pointing  out  the  existing  disease,  rather  leads  us  into  a 
two-fold  error,  by  making  us  consider  the  side  which  yields  the 
dullest  sound  as  diseased,  and  that  which  really  is  so,  as  sound.* 
It  moreover  frequently  happens,  that  when  the  pneumothorax  is 
complicated  with  a  liquid  effusion,  both  sides  sound  equally  well, 
or  even  that  the  affected  side  sounds  less  than  the  other,  accord- 
ing to  the  quantity  of  the  effused  air.  The  comparative  size  of 
the  two  sides  is  not  more  satisfactory.  Not  only  is  the  affected 
side  not  always  larger,  but  it  sometimes  becomes  even  smaller  than 
the  other,  from  the  absorption  of  a  part  of  the  air  and  liquid  con- 
tained in  it.  Even  in  the  cases  where  the  dilatation  of  the  side  is 
obvious,  it  does  not  furnish  any  surer  indication  than  percussion. 
From  its  superior  size  and  resonance,  one  will  be  apt  to  consider 
the  diseased  side  as  sound  and  the  healthy  one  as  contracted,  in 
the  manner  formerly  described.  Mistakes  of  this  kind  we  may 
consider  as  quite  inevitable  ;  or  if,  by  chance,  the  dilatation  and 
tympanic  resonance  point  out  the  disease,  (as  was  done  by  Bayle 
in  a  case  formerly  related,)  it  will  more  frequently  happen  that 
these  signs  shall  deceive  rather  than  assist  us.  This  will  be  more 
fully  shown  in  the  ensuing  section.  I  shall  content  myself  at 
present,  with  remarking,  that  during  the  period  of  my  attend- 
ance on  the  clinical  lectures  of  Corvisart,  I  saw  many  cases  of 
pneumothorax  in  the  dead  body,  none  of  which  had   been  sus- 

With  a  very  little  practice  in  percussion  it  will  not  be  easy  to  confound  the 
very  clear  sound  of  the  chest  in  pneumothorax  with  the  normal  sound.  Per- 
cussion alone  may,  therefore,  be  a  great  help  in  ascertaining  the  existence  of 
gas  in  one  of  the  pleura?  ;  by  this  mode  of  investigation  Bayle  discovered  pneu- 
mothorax in  a  case  mentioned  in  the  following  page.— And  ml. 


PNEUMOTHORAX. 


533 


pected  during  the  life-time  of  the  patient.  No  one  will  refuse  to 
this  celebrated  teacher  either  the  talent  for  observation,  or  the 
ability  to  make  the  most  of  percussion  ;  consequently  the  best  proof 
that  can  be  afforded  of  the  insufficiency  of  this  method  to  detect 
pneumothorax,  is  the  fact  of  his  being  mistaken  in  these  cases. 

The  certain  diagnosis  of  pneumothorax  is  afforded  by  the  com- 
parison   of  the   results   of  percussion  and    mediate  auscultation. 
Whenever  we  find  one  side  of  the  chest  sounding  more  distinctly 
than  the  other,  and,  at  the  same  time,  perceive  the  respiration 
very  well  in  the  least  sonorous   side  and  not  at  all  on  the  other, — 
we  may  be  assured  that  there  exists  pneumothorax  on  the  latter. 
We  may  be  equally  sure  of  our  diagnosis  when  both  sides  are 
alike  sonorous,  and  even  although  the  affected   side  were  some- 
what less  sonorous  than  the  sound  one.     This  latter  case  occurs 
when  the  pneumothorax  supervenes  to  pleuritic  effusion,  or  any 
other  fluid  extravasation.     Here,  before  the  supervention  of  the 
pneumothorax,  the   affected  side   yields  a  perfectly  dull   sound, 
and  the  respiration  is  either  entirely  absent,  or  is  heard  very  in- 
distinctly.    As  soon  as  the  gas  begins  to  accumulate,  the  reso- 
nance of  the  chest  returns,  in  some  degree,  in  the  situation  occu- 
pied by  the  air,  without,  however,  being  as  distinct  as  in  the 
sound  side.     Day  by  day,  the  extent  and  intensity  of  this  reso- 
nance increase,  without  any  return  of  the  sound  of  respiration  ; 
and  if  there  had  previously  been  any  remains  of  the  respiratory 
murmur,  even  this  now  totally  vanishes.     There  is  only  one  cir- 
cumstance which  can   render  the  diagnosis  more  difficult  in  such 
cases:  this  is  the  case  of  the  lung  being  attached  to  the  side  by 
means  of  a  very  short  cellular  tissue :    in  the  point  of  adhesion 
the  respiration  will  be  still  audible  ;  and  an  inattentive  observer, 
who  might  have   applied  the  instrument  on  this  place  only,  might 
still  mistake  this  disease.     It  is  hardly  necessary  to  observe,  that, 
in  pneumothorax,  as  in   pleurisy  and  hydrothorax,  some  degree  of 
respiration  will  be  still  perceptible  in  that  part  of  the  back  corres- 
ponding to  the  roots  of  the  lungs.     Air  being  a  worse  conductor 
of  sound  than  liquids,  it  is  more  difficult  to  perceive  the  respirato- 
ry sound  of  the  healthy  side  on  that  which  is  diseased,  in  pneumo- 
thorax than  in  empyema.     M.  Cayol,  however,  lately  pointed  out 
to  me  a  case  of  this  kind  ;  but  it  is  proper  to  state  that  there  was 
here  a  liquid  as  well  as  a  gaseous  effusion.     I  formerly  pointed 
out  the  means  of  avoiding  the  mistake  in  question. 

The  only  other  disease  which  presents  analogous  signs,  is  em- 
physema of  the  lungs,  the  consequence  of  an  extensive  dry  ca- 
tarrh ;  but  the  differences  between  these  diseases  is  so  striking, 
that  they  could  only  be  mistaken  by  a  very  inattentive  observer. 
These  differences  are  chiefly  in  the  following :  in  the  case  of 
pneumothorax,  the  respiratory  sound  is  completely  lost,  even  in 


53 1  PNEUMOTHORAX. 

the  most  energetic  inspirations,  over  every  part  of  the  chest,  ex- 
cept between  the  scapula  and  spine,  where  it  is  still  audible, 
although  weaker  than  in  the  natural  state.  In  the  case  of  em- 
physema, there  is  never  the  total  loss  of  the  respiratory  sound 
generally,  nor  its  comparative  integrity  at  the  root  of  the  lungs ; 
in  it,  even  in  the  most  severe  cases,  the  respiration  is  still  audible, 
though  very  feeble,  in  some  variable  points.  The  slight  rhonchus 
which  accompanies  the  dry  catarrh,  and  still  less  the  dry  crepi- 
tous  rhonchus  which  is  its  pathognomonic  sign  are  never  present 
in  the  pneumothorax.  The  effusion  of  air  comes  on  suddenly, 
and  cannot  exist  for  any  length  of  time  without  giving  rise  to 
severe  symptoms  and  even  producing  death.  I  have  never  seen 
pneumothorax  in  any  person  who  was  not  confined  to  bed  ;  while 
emphysema  comes  on  gradually,  and  does  not  always  incapacitate 
the  patient  for  exertion,  even  when  existing  in  the  most  intense 
degree  in  both  lungs.  The  signs  just  mentioned  are  the  same  in 
every  variety  of  pneumothorax  ;  but  when  there  exists  a  collection 
of  liquid  as  well  as  air,  we  have  the  want  of  both  respiration  and 
resonance  over  the  part  occupied  by  the  former,  and  the  want  of 
respiration  only  over  the  part  occupied  by  the  latter.  This  com- 
plication, as  well  as  the  fistulous  communication  between  the 
pleura  and  bronchi,  is  moreover  recognized  by  the  Hippocratic 
succussion  ;  and  the  last-mentioned  case  will,  further,  be  in- 
stantly pointed  out  by  the  metallic  tinkling  or  the  amphoric 
buzzing.  The  importance  of  these  two  signs  induces  me  to  ap- 
propriate a  separate  article  to  each  ;  but  I  shall  previously  give 
an  example  of  pneumothorax  recognized  during  the  patient's 
lifetime.*     A  similar  case  was  indeed  formerly  detailed   (Case 

*  Among  the  rational  symptoms  supposed  to  indicate  pneumothorax,  besides 
those  mentioned  in  the  text,  the  following  have  been  particularly  dwelt  on  by 
different  writers :  decubitus,  or  the  posture  assumed  by  the  patient  in  bed  ;  dis- 
placement of  the  heart;  depression  of  the  liver.  In  respect  to  decubitus,  I  be- 
lieve we  may  assert  that  although  different  patients  prefer  different  sides,  yet 
that  the  majority  prefer  lying  on  the  affected  side.  When  the  etlusion  is  on  the 
left  side  there  is  often  great  displacement  of  the  heart  to  the  right  side,  as  in  the 
oase  of  simple  empyema;  and  when  it  is  on  the  right  side,  there  is  frequently  a 
very  marked  depression  of  the  diaphragm  and  liver.  An  observation  recently 
made  by  Dr.  Stokes,  in  a  valuable  paper  on  the  diagnosis  of  empyema,  (Dub. 
Journ.  vol.  iii.  p.  50,)  deserves  notice  in  this  place,  as  it  is  equally  applicable  to 
pneumothorax  as  to  empyema,  if  indeed,  these  two  diseases  were  net  almost  al- 
ways conjoined.  The  observation  refers  to  the  discrimination  of  a  tumid  hypochon- 
dre  produced  by  an  enlarged  liver,  from  one  produced  by  a  sound  liver,  depressed 
from  thoracic  effusion.  "  If  it  be  the  first,"  says  Dr.  Stokes,  "  we  find  the  tu- 
mor presenting  a  continuous  surface  and  feeling  of  resistance  from  its  most  pro- 
minent position  to  where  it  can  no  longer  be  traced  under  the  ribs,  the  lower 
margin  of  which  seems  tilted  out.  But  if  it  be  a  displaced  liver,  we  find,  be- 
tween its  most  convex  portion  and  the  edge  of  the  false  ribs,  a  sulcus,  evident 
to  the  sight  and  to  manual  examination,  presenting  much  less  resistance,  and 
evidently  the  result  of  the  space  left  around  the  point  of  contact  of  two  convex 
bodies,  one  the  tipper  portion  of  the  liver,  the  other  the  most  prominent  point 
of  the  depressed  diaphragm." — Transl. 


PNEUMOTHORAX. 


)35 


XVII.)  and  several  others  will  be  given  at  the  end  of  this  sec- 
tion. The  case  which  I  am  now  to  relate  is  remarkable,  inas- 
much as  the  effusion  of  air  was  detected  at  its  very  formation, 
and  its  progressive  increase  followed  from  day  to  day.  I  could 
have  added  other  cases  of  simple  pneumothorax  supervening  to 
other  diseases  three  or  four  days  before  death  and  instantly  re- 
cognized ;  but  as  they  Were  not  in  other  respects  of  an  interest- 
ing kind,  I  shall  not  here  detail  them.* 

Case    XXXVI. — Pleurisy  followed  by  pneumothorax. — M. 

C ,   a    physician,    of  the  Faculty    of   Paris,   aged  thirty-six, 

was  attacked  in  May,  1822,  with  fever,  diarrhoea  and  cholic, 
complaints  to  which  he  had  been  subject.  He  had  twice  applied 
leeches  to  the  abdomen  before  I  saw  him  on  the  27th.  I  ordered 
them  to  be  repeated,  with  the  effect  of  relieving  his  pains,  but 
not  the  fever.  Finding  that  this  fever  was  of  a  remitting  nature, 
I  prescribed  bark  in  large  doses,  combined  with  tartar  emetic, 
which  cut  short  the  periodical  accessions,  and  left  a  very  slight 
degree  of  fever.  On  the  8th  day  of  this  false  convalescence, 
upon  paying  a  visit  to  the  patient,  (who  considered  himself  as 
almost  cured,)  I  thought  I  observed  the  respiration  to  be  quicker 
than  usual.  In  consequence,  I  applied  the  stethoscope,  and  dis- 
covered all  the  signs  of  an  acute  pleurisy  of  the  right  side,  viz. 
complete  absence  of  respiration  and  resonance,  and  segophony, 
(slight  as  to  degree,  but  of  a  very  sharp  and  bleating  character,) 
over  the  whole  of  the  side  and  even  on  the  upper  parts.  I  had 
never  met  with  so  extended  segophony,  and  I  could  only  account 

*  The  gas  accumulated  in  the  pleura  may  sometimes  escape  through  this 
membrane,  and  by  spreading  throughout  the  cellular  tissue  of  the  walls  of  the 
chest,  give  rise  to  an  emphysema  like  that  arising  from  wounds  in  the  lungs.  I 
have  never  seen  more  than  one  example  of  this  sort,  and  I  believe  no  other  has 
yet  been  described.  In  January,  1836,  I  was  called  to  see  a  young  man  who 
for  a  long  time  had  exhibited  all  the  rational  symptoms  of  pulmonary  phthisis, 
and  for  about  two  days  had  been  much  worse-.  I  examined  his  chest,  and  on 
applying  my  hand  on  the  left  side  of  the  thorax,  was  not  a  little  surprised  to 
feel  under  my  fingers  a  very  distinct  crepitation  :  by  pressure,  I  displaced  a  gas 
which  existed  in  the  areola?  of  the  cellular  tissue,  and  which  under  the  finger 
escaped  from  one  areola  to  another.  The  whole  surface  of  the  left  side  of  the 
chest  was  emphysematous  ;  the  lumbar  region  and  a  portion  of  the  abdominal  walls 
began  to  be  affected  in  the  same  manner.  On  percussion,  the  chest  resounded 
much  louder  on  the  left  than  on  the  right  side.  By  auscultation  I  discovered 
in  the  left  side  of  the  thorax,  posteriorly,  two  signs  which  left  no  doubt  of  the 
existence  of  a  pneumothorax,  caused  by  a  recent  communication  between  a 
tuberculous  cavity  in  the  lung  and  the  pleura.  One  of  these  signs  was  a  very 
distinct  amphoric  resonance  heard  throughout  all  the  left  half  of  the  thorax  at 
each  inspiration.  The  other  was  a  metallic  tinkling,  the  most  distinct  I  ever 
heard.  By  keeping  my  ear  for  some  time  applied  to  the  left  posterior  part  of 
the  thorax,  I  heard  at  intervals,  a  sound  like  grains  of  sand  falling  into  a  metal- 
lic or  glass  vessel.  In  front,  under  the  clavicles,  cavities  existed  in  the  lungs. 
I;  seemed  to  me  clear,  in  this  case,  that  the  atmospherical  air,  escaped  from 
a  tuberculous  cavity  into  the  pleura,  had  infiltrated  through  the  pleura  into  the 
thoracic  parietes.  The  patient  died  the  next  day.  No  autopsy  was  made. — 
Jindral. 


536  PNEUMOTHORAX. 

for  it,  by  considering  the  lung  as  attached  to  the  costal  pleura 
by  ancient  adhesions  in  different  points,  so  as  to  prevent  the 
viscus  from  being  separated  from  the  walls  of  the  chest  to  any 
great  distance.  This  pleurisy  was  completely  latent,  as  there 
was  neither  stitch  nor  oppression,  and  no  more  cough  than  that 
slight  dry  cough  which  attends  almost  all  continued  and  even 
intermittent  fevers.  I  applied  twelve  leeches  to  the  side.  On 
the  following  days  the  aegophony  became  less,  and  gradually  dis- 
appeared over  the  upper  part  of  the  chest ;  the  part  where  it 
began  to  be  heard  becoming  every  day  lower.  Percussion  now 
yielded  the  natural  sound  over  the  space  left  by  the  aegophony, 
but  there  was  no  respiratory  sound  whatever,  although  this  was 
perceived  in  a  very  slight  degree  over  the  lower  two-thirds, 
where  the  aegophony  was  still  strongly  marked,  and  the  sound 
on  percussion  entirely  dead.  It  was  evident  from  these  signs 
that  pneumothorax  had  supervened  to  the  pleuritic  effusion.  I 
did  not  attempt  to  confirm  my  diagnosis  by  means  of  succussion, 
for  fear  of  alarming  the  patient.  As  the  side  was  not  at  all  di- 
lated, and  there  was  no  metallic  tinkling,  I  concluded  that  pneu- 
mothorax was  not  the  consequence  of  a  pulmonary  fistula,  but  of 
simple  exhalation  into  the  pleura ;  and  that  the  sero-purulent 
fluid  was  absorbed  in  proportion  as  the  gas  accumulated.  This 
last  circumstance  was  moreover  quite  evident  from  the  fact, 
that  the  aegophony  and  dead  sound  were  found  to  retreat  daily 
before  the  pneumothorax.  Fifteen  days  from  the  appearance  of 
the  pleurisy,  and  thirty  from  the  attack  of  fever,  aegophony  and 
the  sound  of  respiration  were  confined  to  the  middle  of  the  back. 
The  anterior-superior  half  of  the  left  side  yielded  on  percussion 
a  decidedly  clearer  sound  than  the  other  side  ;  and  on  the  lower 
parts  the  sound  of  respiration  was  entirely  wanting.  From  this 
time  the  patient  gradually  sunk,  with  various  symptoms,  con- 
nected as  well  with  the  fever  as  the  pneumothorax,  and  died  on 
the  17th  July. 

Dissection  thirty  hours  after  death. — Upon  penetrating  the 
left  side  of  the  chest  a  large  quantity  of  inodorous  gas  made  its 
escape  with  a  hissing  sound ;  and  upon  laying  open  the  chest, 
the  lung  was  found  compressed  towards  the  mediastinum,  (no 
doubt  by  the  air  that  had  escaped,)  leaving  a  space  between  it 
and  the  costal  pleura  capable  of  containing  more  than  a  pint  of 
liquid.  The  lung  was  attached  to  the  pleura  of  the  ribs  by  five 
or  six  points,  two  at  its  anterior  border  and  the  other  at  its  outer 
and  posterior  surface,  in  such  manner  that  it  could  not  be  com- 
pletely compressed  against  the  mediastinum,  and  was  not  indeed, 
in  any  point,  more  than  two  inches  distant  from  the  walls  of  the 
chest.  The  lower  and  back  parts  of  this  side  contained  about 
ten  ounces  of  a  bloody  serosity,  and  a  large  quantity  of   false 


SIGNS    AND    SYMPTOMS.  537 

membranes,  of  a  yellow  color,  pretty  thick,  and  of  a  tolerably 
firm  consistence.  The  remaining  part  of  the  pleura  pulmonalis 
was  healthy  :  and  the  costal  pleura  on  its  upper  and  lateral  parts 
was  of  a  dead  white  color  and  of  a  shining  appearance  like  that 
of  cartilage  ;  here  and  there  on  its  surface  there  were  some  tu- 
berosities of  the  size  and  shape  of  hemp-seed,  and  whose  texture, 
as  well  as  that  of  the  pleura  itself,  seemed  intermediate  between 
that  of  the  healthy  pleura  and  fibro-cartilage.  This  portion  of 
the  pleura  was  at  least  a  quarter  of  a  line  thick.  Upon  dissect- 
ing it,  some  tuberculous  masses',  yellow  and  opaque,  and  of  the 
size  of  a  lentil  or  hemp-seed,  but  for  the  most  part  flattened, 
were  found  on  its  exterior  or  adherent  surface,  so  as  to  give  rise 
to  elevations  on  its  inner  surface,  less  regular  in  appearance  than 
the  small  tuberosities  already  described.  The  lung  was  com- 
pressed so  as  to  be  not  larger  than  twice  the  thickness  of  the 
hand.  It  was  of  a  violet  hue,  soft  and  flabby,  but  otherwise 
healthy,  and  did  not  contain  a  single  tubercle.  The  right  lung 
was  universally  adherent  by  means  of  old  cellular  attachments ; 
and  its  upper  lobe  contained  many  tubercles  in  every  stage  of 
their  progress. 

Sect.  III. — Of  Pneumothorax  with  liquid  effusion,  and  of  its 
exploration  by  Succussion  of  the  Chest. 

When  I  first  began  to  make  use  of  the  stethoscope,  I  was  in 
hopes  that  this  instrument  might  furnish  some  sign,  analogous  to 
the  rhonchus,   calculated  to  discover  collections  of  serum  or  pus 
within   the   chest,  by  means   of   fluctuation.     Two  methods  of 
effecting  this  exploration    naturally   presented  themselves :    one 
was  to  percuss  the  chest  on  one  side,  as  in  ascites,  and  apply  the 
stethoscope  to  the   opposite  one ;  the  other  was  to  listen  simply 
to  the    sounds  occasioned  by  the  agitation  of  the  fluid   from  the 
natural  action  of  the   heart  and   lungs.     A  little  reflection  might 
have  convinced  me  of  the   unlikelihood  of  my  expectations ;  yet 
this  conviction  did   not  arise  till   after  many  vain  attempts  to  ob- 
tain the  object  I  had  in  view.     I  ascertained  that  the  instrument 
readily  communicated   the   shock   in  the  cases   of  ascites ;  but  I 
never  could  obtain  a  similar  result  in  the   case  of  thoracic  effu- 
sions :  and  the  reason  of   this  is  obvious.     On  account  of  the 
solid  and  bony  character  of  the  walls  of  the  chest,  the  percussion 
used  to  produce  the  fluctuation,  conveys  more  impulse  and  sound 
to  the  ear  of  the  observer,  than   does  the  shock  produced  by  the 
liquid,  and   consequently   completely  masks  the  latter.     This  re- 
sult is  a  necessary  consequence  of  the  known  principle  that  solids 
communicate  impulse  and  sound  better  than  fluids.     In  the  case 
of  ascites,  the  shock  communicated  to  one  side  of  the  abdomen, 
68 


538  PNEUMOTHORAX. 

is  not  transmitted  by  the  abdominal  parietes  on  account  of  their 
softness;  and  in  aeriform  collections  in  this  cavity,  the  impulse 
is  not  conveyed  by  the  air,  on  account  of  its  being  a  worse  con- 
ductor than  fluid. 

Simple  auscultation  would   seem,  from   reasoning,  to  be  more 
capable  of  supplying  some  signs  of  the  effusion  of  fluids  into  the 
pleura ;  but  from  causes  to  be  hereafter  detailed,  it  will  appear 
evident,  that  this  could  only  be  the  case  when  there  existed  at 
the  same  time  a  liquid  and  aeriform  effusion,  and  when  fluctuation 
was  excited  by  means  of  a  severe  cough.     The  thing,  however, 
does  not  seem   altogether  impossible  ;   although  I  am   doubtful 
if  it  ever  yet  was  observed.     I  have  already  stated  that  we  can 
sometimes  distinctly  hear  fluctuation  in  tuberculous  excavations 
of  considerable  size,  when  they  are  only  half  filled  with  a  very 
liquid  matter ;  and  this  is  easily  explained  by  the  relative  con- 
dition of  the  parts  concerned  in  the  production  of  this  pheno- 
menon.    In  this  case   the  quantity  of  fluid  to  be  moved  is  small, 
the  communication  with  the  bronchi  is  usually   narrow,  and    the 
soft  walls  of  the  excavation  are  strongly  impressed   both  by  the 
mediate  and  immediate   compressions   produced  by  the  cough. 
Air  effused  into  the  pleura,  on  the  contrary,  almost  always  com- 
municates with  the  air  in  the  larger  bronchi,  by  means  of  a  short 
and  wide  channel ;  and  being  confined  between  the  bony  walls  of 
the  chest  and  the  lung  bound   down  against  the   spinal  column, 
it  is  very  little  susceptible  of  compression,  much  less  of  agitation, 
by  the  action  of  coughing.     The   fistulous  opening  is,  moreover, 
rarely  situated  below  the  level  of  the  fluid.     For  these  reasons, 
then,  I  am  of  opinion,  that  the  cough  will  hardly,  in  any  case, 
occasion    an    audible  fluctuation  of   a  liquid    contained    in  the 
pleura ;  and  we  may  be  assured  that,  whenever  such  fluctuation 
is  heard,  the  cause  of  it  is  situated  in  an   ulcerous  excavation. 
We  can  have  still  less  expectation  of  hearing  any  sounds  of  this 
kind  by  simple  auscultation,  independently  of  coughing.     I  have 
repeatedly  endeavored  to  do  this,  in  cases  wherein  the  co-exist- 
ence of  air  and  liquid  was  proved  by  other  means,  and  always 
unsuccessfully.    In  cases  of  simple  hydrothorax  or  empyema  with- 
out any  accompanying  extravasation  of  air,  the   impossibility  of 
doing  this,  is  still  more  clearly  demonstrated. 

I  ought  to  be  the  less  surprised  at  these  unsuccessful  results  of 
my  attempts,  as  Hippocrates  himself,  as  I  have  elsewhere  shown, 
committed  the  same  mistake.  But  if  auscultation  by  itself  can- 
not, as  Hippocrates  supposed,  detect  the  presence  of  a  fluid  in 
the  chest,  we  obtain  at  least  from  the  writings  of  this  great  man, 
or  those  of  his  disciples,  a  sign  very  characteristic  of  this  affec- 
tion, in  one  particular  form  of  it.  This  method  of  exploration, 
which  perhaps  has  never  been  practised  but  by  the  Asclepiades, 


SUCCUSSION    OF    THE    CHEST.  539 

consists  in  shaking  the  patient's  trunk,  and  at  the  same  time 
listening  to  the  sounds  thereby  produced.  This  process  is  de- 
scribed by  the  author  of  the  treatise  De  Morbis  (lib.  ii.  45)  in 
the  following  terms :  "  Having  placed  the  patient  in  a  firm  seat, 
cause  his  hands  to  be  held  by  an  assistant,  and  then  shake  him 
by  the  shoulder,  in  order  to  hear  on  which  side  the  disease  shall 
produce  a  sound."  Although  this  method  is  described  in  a  work 
which  is  not  unanimously  attributed  to  Hippocrates,  we  cannot 
doubt  of  its  having  been  known  to  him,  and  of  its  having  been  a 
common  practice  among  his  followers  :  many  passages  in  the  Hip- 
pocratic  writings  either  speak  of  it  formally,  or  by  implication. 
On  this  point,  as  on  several  others,  the  Asclepiades  have  gene- 
ralized too  much  on  the  facts  observed  by  them :  every  where 
they  mention  this  method  as  a  sure  means  of  recognizing  em- 
pyema ;  and  yet  there  cannot  be  a  doubt,  as  will  be  shown  here- 
after, that  the  simple  empyema  was  never  so  detected.  It  is,  no 
doubt,  owing  to  the  fruitless  attempts  made  in  different  times  to 
discover  the  simple  disease  in  this  manner,  to  which  we  are  to 
attribute  the  entire  abandonment  of  the  method  in  question.  So 
complete,  indeed,  has  been  this  abandonment,  that  in  reading  the 
Commentators  of  Hippocrates  we  do  not  find  a  single  indication 
of  the  plan  having  been  ever  put  in  practice  by  any  of  them  ; 
and  we  even  find  that  the  cleverest  of  them  do  not  seem  to  have 
always  well  understood  the  passages  in  which  it  is  mentioned. 
Succeeding  practitioners  appear  to  have  paid  as  little  attention 
to  it ;  although  most  of  the  systematic  writers  on  surgery  men- 
tion it,  but  doubtfully,  and,  as  it  would  seem,  merely  out  of  re- 
spect to  Hippocrates.  I  know  of  no  author  who  states  his 
having  himself  practised  it ;  but  a  few  observers  mention  cases 
in  which  the  spontaneous  movements  of  the  chest,  produced 
a  sound  of  fluctuation  perceptible  by  the  patient,  and  some- 
times by  the  attendants.  Morgagni  was  witness  of  a  fact  of  this 
kind,*  and  has  recorded  four  others  observed  by  Fanton,f  Mau- 
chart,J  Wolff,§  and  Willis.  ||  To  these  we  ought  to  add  another 
noticed  by  Parelf  but  omitted  by  Morgagni,  and  perhaps  some 
more  that  have  escaped  my  research  as  well  as  his.  At  all  events, 
cases  of  this  kind  have  hitherto  been  considered  as  extremely  rare. 
None  of  the  observers  just  mentioned,  seem  to  have  thought  of 
ascertaining,  even  in  the  cases  described  by  themselves,  whether 
succussion  would  produce  the  sound,  as  well  as  the  spontaneous 
movements  of  the  patient ;  and  some  of  them,  particularly  Mor- 

*  De  Sed.  et  Caus.  Morb.  Ep.  xvi.  art.  xxxvi.  f  Anat.  obs.  xxix. 

t  Ephem.  Nat.  Cur.  Cent.  vii.  obs.  c.     §  J.  P.  Wolff  ii.  Ibid.  torn.  t.  obs.  xxxiv. 
||  Sepulchret.  lib.  ii.  Schol.  ad  obs.  lxxv. 
IT  CEuvr.  d'Ainbroise  Pare,  liv.  viii.  chap.  x. 


540  PNEUMOTHORAX. 

gogni  and  Fanton,  have  even  endeavored  to  show  that  the  method 
of  Hippocrates  can  be  productive  of  no  result. 

This  opinion  is,  no  doubt,  quite  correct,  in  relation  to  the  class 
of  cases  considered  by  them,  viz.  collections  of  fluids  simply, 
without  any  accompanying  air.  The  sound  of  fluctuation  cannot, 
in  fact,  be  ever  perceived  in  simple  empyema  or  hydrothorax, 
even  under  the  most  powerful  succussion,  as  I  have  many  times 
proved.  When,  however,  pneumothorax  is  conjoined  with  either 
of  these  affections,  the  phenomenon  is  distinctly  perceptible. 
Sometimes,  also,  the  spontaneous  movements  of  the  patient  in 
bed,  or  while  walking,  produce  a  fluctuation  sufficiently  loud  to 
be  heard  by  himself  or  the  bystanders.  In  some  of  the  cases 
which  I  shall  relate,  this  phenomenon  was  present ;  but  the  only 
practitioner  whom  I  have  met  with,  that  has  noticed  a  similar 
fact,  is  M.  Boyer :  he  informs  me  that  he  saw  a  young  man,  in 
consultation  with  MM.  Halle  and  Jeanroi,  who  very  distinctly 
perceived  the  sound  of  fluctuation  within  the  chest,  when  coming 
down  stairs.  When  the  sound  cannot  be  perceived  by  the  naked 
ear,  on  account  of  its  feebleness,  the  stethoscope  enables  us  to  do 
so  very  distinctly,  as  will  be  seen  in  two  of  the  cases  at  the  end 
of  this  chapter.  Such  a  circumstance  will  particularly  occur  at 
the  commencement  of  the  effusion  of  air,  and  while  this  is  still  in 
small  quantity.  As  soon  as  the  accumulation  becomes  considera- 
ble, the  sound  is  heard  very  distinctly  by  the  unassisted  ear.  In 
some  cases  I  have  observed,  that  the  motion  of  the  fluid  could  be 
perceived  by  the  hand  during  the  alternate  stooping  and  raising 
of  the  chest. 

The  Hippocratic  fluctuation  is  among  the  few  signs  which  of 
themselves  convey  to  the  least  experienced  observer,  a  full  and 
entire  conviction  of  the  existence  of  the  disease.  Nevertheless, 
there  are  still  some  cases  in  which  it  must  not  be  received  with 
unlimited  confidence.  I  have  already  observed,  that  the  same 
phenomenon  may  take  place  in  the  case  of  a  very  large  tuber- 
culous excavation  half  full  of  liquid.  Such  a  case,  however,  is 
very  rare,  and  it  has  never  occurred  to  me  but  once.  In  this 
instance,  the  lower  two-thirds  of  the  right  lung  were  occupied 
by  a  vast  excavation,  in  such  manner  that  the  lung  formed 
merely  the  walls  of  the  cyst,  being  every  where  adherent  to  the 
walls  of  the  chest  and  reduced  to  the  thickness  of  only  one  or 
two  lines :  in  one  point,  about  the  size  of  the  palm  of  the  hand, 
the  pleura  itself  appeared  to  form  the  immediate  boundary  of 
the  excavation.  I  must  admit  that  such  a  case  as  this  cannot  be 
distinguished  from  pneumothorax  with  liquid  effusion  and  bron- 
chial fistula,  unless  one  had  had  an  opportunity  of  watching  it 
from  the  beginning.  There  is  likewise  another  circumstance 
which  might  mislead  an  inexperienced  observer :  some  persons 


SUCCUSSION    OF    THE    CHEST. 


541 


whose  stomachs  constantly  contain  air,  after  having  drunk  a  cer- 
tain quantity  of  fluid,  exhibit  the  phenomena  of  fluctuation, 
upon  the  trunk  being  shaken.  One  of  my  pupils  possessed  this 
power  in  an  eminent  degree,  and  sometimes  used  to  amuse  his 
comrades  with  the  exhibition  of  it.  This  error,  however,  is  very 
easily  avoided ;  as  the  alternate  application  of  the  stethoscope  to 
the  chest  and  epigastrium  readily  points  out  the  source  of  the 
sound.  Besides,  in  this  case  always,  and  in  the  greater  number 
of  instances  in  which  fluctuation  is  afforded  by  a  tuberculous 
excavation,  the  absence  of  the  other  signs  supplied  by  percussion 
and  auscultation,  will  prevent  us  from  committing  the  mistake  in 
question. 

Although  Hippocrates  was  unacquainted  with  pneumothorax, 
in  one  of  the  passages  where  he  speaks  of  succession,  we  find 
some  remarks,  which  if  they  had  been  often  repeated,  would 
have  necessarily  led  to  the  knowledge  of  this  disease  and  of  its 
co-existence  with  empyema  in  every  case  in  which  succussion  of 
the  chest  produces  the  sound  of  fluctuation.  The  passage  is  the 
following  :  "  Among  the  patients  affected  with  empyema,  those 
who  produce  most  sound,  when  shaken  by  the  shoulder,  have  less 
pus  in  the  chest  than  those  who  yield  less  sound,  and  who  are 
more  flush  and  breathless:  in  respect  of  those  who  do  not 
yield  any  sound,  but  who  have  the  nails  livid  and  a  great  dys- 
pnoea, they  are  full  of  pus,  and  their  case  is  desperate."  (Preen. 
Coac.  ii.  432.)  And  at  the  end  of  the  passage  in  which  the  suc- 
cussion of  the  chest  is  described,  the  author  adds  that  "  some- 
times (wore)  the  thickness  and  quantity  of  the  pus  prevent  us 
from  hearing  the  fluctuation."  (De  Morb.  ii.  45.)  These  pas- 
sages ought  to  convince  us  that  the  Asclepiades  had  an  idea  that 
there  must  be  some  vacuity  in  the  chest  before  a  fluid  contained 
in  it  can  produce  any  sound  ;  in  the  same  manner  as  wine  con- 
tained in  a  bottle  when  shaken,  yields  the  more  sound  the  more 
empty  it  is.  Indeed  one  of  the  commentators  makes  use  of  this 
very  comparison  ;  but  the  notions  entertained  by  them  on  this 
subject  were  confused  and  imperfect :  they  imagined  a  vacuum 
in  some  part  of  the  chest,  which  we  know  cannot  exist.  Even 
Morgagni  had  hardly  more  correct  ideas  on  this  subject ;  for 
after  having  stated  that  the  fluctuation  cannot  be  perceived  when 
either  the  fluid  is  in  very  great  or  very  small  quantity,  he  adds — 
"at  saltern,  inquies,  eo  temporis  spatio,  quo  ab  exigua,  copia 
aqua  crescit,  nee  ad  summum  tamen  adhuc  pervenit,  ejus  fluc- 
tuatio  videtur  percipi  debere.  Videtur  utique.  Sed  quidam 
certe  non  percipiunt, — alii  non  attendunt :  alii  denique  non  in- 
dicant medicis — Humeros  vero  apprehendere,  et  concutere  aut 
aliter  agitare  non  omnes  segros  sane  licet."  (Epist.  xvi.  37.) 
We  further  gather   from  this   passage   that  Morgagni,  without 


542  PNEUMOTHORAX. 

absolutely  denying  the  possibility  of  fluctuation  in  these  cases, 
considered  the  sign  as  almost  useless,  on  account  of  its  great  in- 
frequency ;  while,  on  the  other  hand,  he  considered  succussion 
as  attended  with  such  inconveniences  as  ought  to  cause  its  rejec- 
tion in  most  cases.  This  opinion,  however,  is  totally  unfounded. 
When  properly  used,  succussion  ^is  not  more  fatiguing  to  the 
patient  than  the  percussion  of  the  chest,  or  the  examination  of 
the  abdomen  by  compressing  its  contents.  To  enable  us  to  hear 
the  sound,  it  is  not  necessary  to  shake  the  body  much :  all  that  is 
required  being  merely  to  shake  the  shoulder  pretty  quickly,  and 
to  stop  all  at  once.  I  have  employed  this  mode  of  exploration 
in  the  case  of  a  great  number  of  patients,  several  of  whom  were 
in  a  state  of  great  suffering  and  debility  ;  and  yet  I  never  heard 
any  complaints  of  it.  There  are  no  grounds,  therefore,  for 
leaving  it  in  the  oblivion  into  which  it  has  fallen.  The  cases  in 
which  it  supplies  us  with  certain  signs  are  much  more  common 
than  might  be  supposed  from  the  small  number  of  examples  on 
record.  Sufficient  proof  of  this  is  supplied  by  the  five  following 
cases,  which  occurred  in  the  course  of  a  single  year  in  an  hospital 
containing  one  hundred  beds.  Three  other  cases  of  the  same 
sort,  one  of  which  I  have  already  noticed  (Case  XVII.)  were  ob- 
served during  the  same  period.  Since  the  publication  of  the  first 
edition  of  this  work,  I  have  seen  at  least  thirty  similar  cases,  and 
I  have  had  occasion  to  know  of  many  others  in  the  hospitals  of 
Paris.  There  are  certainly  many  much  rarer  diseases,  which  are 
better  understood. 

Case  XXXVII. — Pleurisy  and  Pneumothorax,  with  fistulous 
communication  between  the  pleura  and  bronchi.  A  man,  aged 
thirty,  was  attacked  for  the  first  time,  in  May,  1817,  with  a  ca- 
tarrhal affection,  attended  by  a  cough,  dyspnoea,  &c.  which  con- 
tinued, with  variable  severity,  until  the  beginning  of  November, 
when  he  came  under  my  care  in  the  Necker  Hospital.  At  this 
time  there  were  considerable  emaciation,  hot  skin,  small  and 
frequent  pulse,  short  and  quick  respiration,  much  cough,  and 
considerable  expectoration  of  opaque,  yellow,  and  rather  viscid 
sputa.  On  percussion,  the  chest  afforded  an  imperfect  sound  on 
the  upper  and  fore  parts  of  the  right  side,  only  a  middling  sound 
between  the  scapula,  particularly  on  the  right  side,  and  a  good 
sound  every  where  else.  The  stethoscope  detected  the  respiratory 
sound  over  the  whole  chest,  only  it  was  somewhat  feebler  than 
natural  below  the  clavicles,  particularly  the  right.  Pectoriloquy 
existed,  though  rather  doubtful,  below  the  right  clavicle  and  in 
the  axilla.  The  action  of  the  heart  was  natural.  Diagnosis: 
Tuberculous  phthisis.  On  the  12th,  pectoriloquy  was  distinct 
under  the  right  clavicle  and  in  the  axilla  of  the  same  side  ;  and 
the  respiration  was  more  perceptible  over  the  whole  of  the  left, 


PNEUMOTHORAX.  543 

than  on  the  right  side.  I  therefore  added  to  my  diagnosis : — 
tuberculous  excavations  in  the  summit  of  the  right  lung.  On 
the  18th,  metallic  tinkling  was  perceptible  in  the  same  points. 
Between  this  time  and  the  end  of  December,  the  fever  became 
greater  and  the  emaciation  greatly  increased.  Acute  pains  in 
different  parts  of  the  chest  supervened  ;  at  the  same  time,  the 
cough  became  more  troublesome,  and  to  the  yellow  opaque  sputa 
there  was  now  superadded  a  copious  discharge  of  transparent 
and  frothy  mucus.  Percussion  of  the  thorax  yielded  a  much 
clearer  sound  on  the  right  than  on  the  left  side,  where  it  was 
almost  dull  about  the  third  rib ;  while  the  respiratory  murmur 
was  distinct  in  the  latter,  and  not  at  all  perceptible  in  the  former, 
except  along  the  vertebral  column.  The  metallic  tinkling  also 
continued  to  be  very  audible  on  the  right  side.  The  patient  lay 
almost  constantly  on  the  right  side,  the  intercostal  spaces  of 
which  could  now  be  perceived  to  be  wider  and  more  prominent 
than  natural,  and  the  subcutaneous  veins  more  obvious.  All 
these  symptoms  indicated  the  supervention  of  a  pleurisy,  with 
effusion  of  both  air  and  a  liquid  of  some  sort  into  the  right  side 
of  the  chest ;  and  I  accordingly  added  to  my  diagnosis — Pleurisy 
with  effusion,  and  pneumothorax.  Towards  the  end  of  January, 
the  patient  first  perceived  the  fluctuation  of  a  liquid  in  his  chest 
when  he  turned  himself:  the  same  thing  was  very  distinctly 
heard  by  the  bystanders  when  the  trunk  was  shaken  in  a  sitting 
posture.  It  was  difficult  to  distinguish  by  the  naked  ear  on 
which  side  of  the  chest  the  sound  existed,  but  the  difficulty  was 
immediately  removed  by  the  application  of  the  stethoscope, 
(without  the  stopper,)  the  fluctuation  being  distinctly  heard  on 
the  right  side  and  not  at  all  on  the  left.  In  February,  the  sputa 
amounted  to  about  six  ounces  in  twenty-four  hours  ;  they  were 
yellow,  opaque,  and  puriform,  intermixed  with  bubbles  of  air, 
and  swimming,  as  it  were,  in  a  large  proportion  of  a  transparent 
and  diffluent  mucus,  in  which  there  were  sometimes  streaks  of 
blood.  One  day  in  this  month,  he  expectorated,  after  a  fit  of 
coughing,  as  much  as  he  •  usually  did  in  the  whole  twenty-four 
hours.  At  this  time  the  operation  of  empyema  was  performed, 
between  the  sixth  and  seventh  ribs,  by  means  of  a  trocar  only 
one  line  in  diameter.  Two  pounds  of  matter  flowed  in  twenty 
minutes.  This  matter  was  puriform,  opaque,  of  a  slightly 
greenish  yellow  color,  and  scarcely  fetid.  As  it  flowed  it  was 
intermixed  with  some  air-bubbles :  and  on  settling,  it  separated 
into  two  portions, — the  one,  opaque  and  yellow,  and  composed 
of  small  yellowish  flocculi, — the  other,  thinner  and  transparent. 
At  the  end  of  twenty  minutes  the  discharge  became  intermittent, 
and  each  expiration  was  accompanied  by  the  expulsion,  with  a 
loud  sound,  of  a  great  quantity  of  air  through  the  canula.     The 


544  PNEUMOTHORAX. 

instrument  was  then  withdrawn,  and  the  natural  retraction  of  the 
skin  immediately  destroyed  the  apposition  of  the  wounds  in  the 
integuments  and  intercostal  muscles.  Immediately  after  the 
operation,  the  metallic  tinkling  was  heard  much  louder  than 
before.  The  patient  felt  relieved  in  proportion  as  the  matter 
flowed,  and  this  alleviation  continued  for  two  days,  but  he  sunk 
on  the  12th  day  after  the  operation. 

On  examining  the  body  after  death,  we  found  that  the  suc- 
cussion  of  the  trunk  produced  the  sound  of  fluctuation  as  before. 
On  puncturing  the  right  side  of  the  thorax,  which  was  larger 
than  the  left,  a  gaseous  fluid  escaped,  and  it  was  found  to  contain 
two  pints  of  a  sero-purulent  fluid.  The  whole  extent  of  the 
pleura,  on  this  side,  was  lined  by  a  thick  layer  of  coagulable 
lymph,  the  consistence  of  which  varied  in  different  places,  from 
that  of  soft  cheese  to  one  nearly  equal  to  that  of  cartilage :  it 
was  softer  on  the  surface,  and  more  dense  where  it  touched  the 
pleura.  It  was  several  lines  thick  on  the  lungs,  and  on  the  right 
side  of  the  mediastinum  and  diaphragm  ;  it  was  thinner,  softer, 
and  more  easily  detached,  on  the  pleura  of  the  ribs  and  remain- 
ing portion  of  the  diaphragm,  both  of  which  were  of  an  intense 
punctuated  red  color.  The  pleura  of  the  lungs  had  none  of 
this  punctuated  appearance,  and  the  layer  in  contact  with  it, 
which  was  of  a  cartilaginous  firmness,  could  not  be  detached  from 
it.  The  lung  was  compressed  towards  the  spine  and  posterior 
part  of  the  ribs,  (to  which  it  closely  adhered,)  so  that  it  hardly 
occupied  one-third  part  of  the  cavity.  The  pulmonary  tissue 
was  flaccid,  but  still  somewhat  crepitous,  and  permeable  to  the 
air  in  its  posterior  part.  There  were  several  tubercles  in  this 
lung,  from  the  size  of  a  cherry-stone  to  that  of  a  filbert,  and 
almost  all  softened  to  the  consistence  of  curd.  Five  of  these,  of 
a  somewhat  larger  size,  quite  softened  and  nearly  empty,  com- 
municated on  the  one  side  with  the  bronchi,  and,  on  the  other, 
with  the  cavity  of  the  pleura,  by  openings  of  from  one  to  three 
lines  in  diameter.  The  left  lung  was  of  the  natural  size,  and 
contained  also  a  great  many  tubercles  in  different  stages  of  ma- 
turity : — the  greater  number  being  small  and  diaphanous  ;  a  few, 
quite  softened  but  not  communicating  with  the  bronchi.  The 
mucous  membrane  was  very  red  through  its  whole  extent,  and 
exhibited  a  small  ulcer  in  the  posterior  part  of  the  larynx. 
There  was  a  small  quantity  of  serum  in  the  pericardium,  and 
also  in  the  peritoneum. 

Case  XXXVIII. — Acute  pleurisy  and  pneumothorax  in  a 
phthisical  patient. — A  man,  aged  twenty,  who  had  been  unwell  (he 
said)  for  six  months,  and  who  had  suffered  from  diarrhoea  for 
the  three  last,  came  into  the  hospital  in  January,  exhibiting  all 
the  usual  symptoms  of  confirmed  phthisis.     The  chest  sounded 


PNEUMOTHORAX. 


545 


badly  on  percussion  on  the  upper  part  of  the  right  side  before, 
and  on  the  upper  part  of  the  left  side  behind.  Pectoriloquy  was 
very  evident  on  the  right  side,  below  the  clavicle,  in  the  axilla, 
and  also  on  the  shoulder  between  the  upper  edge  of  the  trapezius 
muscle  and  clavicle.  The  patient  remained  long  in  a  stationary 
state.  In  February,  the  pectoriloquy  was  accompanied  by  the 
veiled  puff.  In  the  beginning  of  March,  a  sudden  alteration  took 
place  in  the  symptoms ;  the  respiration  becoming  more  difficult, 
attended  with  pricking  pains  in  the  right  side,  the  pulse  getting 
quicker,  the  skin  hotter,  and  the  face  flushed.  On  examining 
the  chest  at  this  time  by  percussion  and  the  stethoscope,  it  was 
found  that  it  yielded  a  good  sound  over  the  whole  anterior  parts, 
and  that  the  upper  portion  of  the  right  side,  which  on  the  day 
before  had  yielded  only  a  dull  sound,  now  resounded  more  than 
the  other ;  while  the  respiration  was  very  perceptible  on  the  left 
side,  and  not  at  all  on  the  right.  These  symptoms  I  regarded 
as  indicating  pleurisy,  arising  from  the  irruption  of  tuberculous 
matter  into  the  cavity  of  the  pleura,  and  attended  both  by  liquid 
and  jraseoiis  effusion.  I  wished  further  to  ascertain  the  effusion 
by  succussion  of  the  chest,  but  the  patient  was  too  weak  to 
undergo  the  trial,  and  he  died  four  days  after  the  marked  change 
in  the  symptoms. 

The  fluctuation  of  the  fluid  in  the  right  cavity  of  the  chest 
was  very  perceptible,  on  succussion,  after  death.  This  side  ap- 
peared, also,  larger  than  the  left ;  when  struck  it  emitted  a  clear 
sound  ;  and  when  punctured  an  elastic  fluid  escaped  from  it  with 
a  hissing  noise.  There  was  found  in  the  cavity  of  the  pleura  a 
considerable  quantity  of  a  sero-purulent  liquid,  of  a  greenish- 
yellow  color,  very  frothy  on  the  surface,  and  semi-transparent, 
notwithstanding  the  great  portion  of  puriform  fragments  that 
floated  in  it.  The  pleura  was  lined  throughout  with  an  opaque 
albuminous  exudation,  of  a  yellowish-white  color,  easily  scraped 
off  by  the  scalpel,  and  of  the  consistence  of  curdled  milk.  This 
layer  was  of  considerable  thickness  on  some  parts  of  the  ribs  and 
diaphragm,  and  thinner  on  the  lungs.  The  lung  on  this  side 
was  compressed  into  one  third  or  one  fourth  its  natural  volume 
against  the  spine  and  mediastinum,  to  which  last  it  closely  ad- 
hered. It  was  flabby  and  very  imperfectly  crepitous  through 
its  whole  extent,  and  contained  hard  tumors,  which  were  evi- 
dently tubercles.  On  the  closest  examination  no  opening  could 
be  discovered  on  its  surface.  In  the  very  summit  of  the  superior 
lobe  there  were  found  three  tuberculous  excavations;  two  of 
which,  of  the  size  of  an  hazel  nut,  were  full  of  soft  matter,  and 
the  third,  six  times  as  large,  and  capable  of  containing  a  pullet's 
eoo-,  nearly  empty.  This  vast  cavity  was  lined  by  two  mem- 
branes, the  interior  (that  in  immediate  and  close  contact  with  the 
69 


546  PNEUMOTHORAX. 

pulmonary  tissue)  of  a  semi-cartilaginous  density,  and  the  ex- 
terior soft,  almost  entirely  opaque,  and  easily  torn.  The  former 
existed  only  in  some  points ;  the  latter  was  complete.  On  the 
anterior  parts,  this  cavity  was  only  separated  from  the  surface 
by  the  thickness  of  the  pleura  and  the  two  membranes  just  de- 
scribed ;  a  state  of  parts  which  accounts  for  the  phenomena  of 
the  veiled  puff.  The  remainder  of  the  lung  was  filled  by  miliary 
tubercles.  The  left  lung  appeared  quite  sound,  only  containing 
a  few  miliary  tubercles. 

Case  XXXIX. — Chronic  pleurisy  and  pneumothorax  occa- 
sioned by  the  rupture  of  a  tuberculous  excavation  into  the  cavity 
of  the  pleura. — A  man,  thirty-five  years  of  age,  while  in  an  hos- 
pital for  a  chronic  affection  of  the  knee,  was  suddenly  attacked, 
in  January,  with  pleuritic  symptoms,  viz.  head-ache,  pain  in  the 
chest  aggravated  by  respiration,  frequent  cough,  and  expectora- 
tion of  white  and  very  copious  sputa.  Getting  better  he  left  the 
hospital  in  the  end  of  February,  but  returned  again  in  March. 
On  his  admission  into  the  Necker  Hospital  on  the  14th,  he  pre- 
sented the  following  symptoms :  skin  somewhat  hot  and  dry, 
pulse  frequent,  dyspnoea,  frequent  cough  with  a  slight  expecto- 
ration of  frothy  mucus.  The  chest  on  percussion  yielded  the 
dead  sound  over  the  whole  of  the  left  side,  and  sounded  pretty 
well  on  the  right  side.  On  the  left  side,  respiration  was  inaudible, 
except  along  the  spine,  and  even  here  it  was  very  feeble,  and  ac- 
companied by  a  slight  sibilous  rhonchus:  it  was  distinct  on  the 
right  side.  Pectoriloquy  existed  in  the  supra-spinal  fossa  of  the 
right  scapula.  Succussion  of  the  trunk  produced  no  sound.  In 
consequence  of  these  signs  the  following  diagnosis  was  given : 
Phthisis,  chronic  pleurisy  with  considerable  extravasation  on 
the  left  side.  On  the  20th  March,  doubtful  pectoriloquy  was  found 
below  the  left  clavicle ;  and  on  the  ]  6th  April,  perfect  pecto- 
riloquy was  found  in  the  same  place.  The  same  symptoms  con- 
tinued, with  increase  of  emaciation  and  cough,  in  June  and  July. 
In  August,  diarrhoea  supervened,  with  still  greater  cough  and 
fetid  purulent  expectoration,  to  the  amount,  for  a  short  time,  of 
a  pound  and  a  half  in  the  twenty-four  hours.  In  October,  there 
was  again  copious  fetid  expectoration,  with  dyspnoea  and  much 
cough,  and  inability  to  lie  on  the  right  side.  At  this  time,  both 
sides  yielded  the  same  sound  on  percussion,*  but  respiration 
could  be  perceived  in  the  right  side  only.  Fluctuation  in  the 
left  side  was  also  perceptible  on  succussion,  by  means  of  the 
cylinder,  but  not  without  it.  The  patient  said  that  a  momentary 
attempt  to  lie  on  the  right  side  increased  the  frequency  of  the 
cough,  and  greatly  augmented  the  expectoration.     He  was  not, 

*  The  return  of  natural  sound  on  the  left  side,  with  the  continued  absence  of 
the  respiration,  indicated  the  development  of  pneumothorax. — dulltor. 


PNEUMOTHORAX. 


547 


however,  sensible  of  any  fluctuation  in  the  chest.     He  died  in 
the  beginning  of  November. 

On  examination  after  death,  the  left   side  of  the  thorax  was 
found  large*  than  the  right ;  the  left  intercostal  spaces  were  wider 
and   raised   to  a  level  with  the  ribs,   while  the  right  were  sunk 
below  that  level.     On  puncturing  the  thorax  on  the  left  side,  an 
extremely   fetid  gas  made   its  escape  with  a  hissing  sound.     On 
laying  it  open,  it   was  found   to  contain  about    three    pints  of  a 
blackish-grey   liquid,   extremely   fetid,   and  having  somewhat  of 
the    smell   of  garlic.     The    lung   on    this  side   was    compressed 
against  the  spine,  and  was  not  larger  than  the  hand.     Its  surface 
was  covered  with  a  layer  of  a  half-concrete  white  matter,  inter- 
mixed with  a  very  soft  black  substance.     On  it  there  were  two 
openings  of  the   size  of  the  finger,  which  terminated,  interiorly, 
in  the  substance  of  the   lungs,  in  culs-de-sac  not  communicating 
with  the  bronchi.     They  were  evidently  the  remains  of  tubercular 
excavations  which  had  discharged  their  contents  into  the  cavity 
of  the  pleura.     The  whole  of  the  false  membrane  which  invested 
the   pleura  was  black  and  soft  on  the  surface,  but  below  this  it 
was  firmer  and   whitish.     The  right  lung  adhered  to  the  pleura, 
throughout,  by  old  attachments,  and  contained  internally  a  great 
number  of  miliary  tubercles.     In   its  upper  lobe  there  was  an 
empty  excavation  of  the  size  of  a  filbert,  lined   by  a  well  organ- 
ized semi-cartilaginous  membrane.     In  the  middle  of  the  same 
lobe  there  were  found  several  white  bands  resembling  ancient 
cicatrices.     Two  of  these  united  in  the  form  of  the  letter  V,  and 
contained  between  them  a  mass  of  tuberculous  matter.* 

Case  XL. — Pneumothorax  with  pleuritic  effusion.  A  woman, 
aged  twenty-six,  came  into  the  Necker  Hospital  in  January, 
1819,  having  been  ill  three  months  with  what  she  called  a  cold. 
The  chest  yielded  a  middling  good  sound  every  where,  except 
on  the  upper  part  of  the  left  side,  where  the  sound  was  duller. 
In  the  same  place  imperfect  pectoriloquy,  and  also  cavernous 
respiration,  existed  ;  and  in  the  axilla  of  the  same.side,  a  distinct 
cavernous  rhonchus  wras  perceived.  The  diagnosis  was  therefore 
given — Tubercles  in  the  lungs  ;  excavation  in  the  top  of  the  left 
lung.  As  this  patient  was  clearly  in  a  hopeless  state,  she  was 
not  often  examined.  On  the  17th  March  the  metallic  tinkling 
was  found  very  distinctly  on  the  upper  part  of  the  left  side,  which 
was  now  found  to  sound  much  better  than  the  right.  Respira- 
tion was  good  on  the  right  side,  but  was  inaudible  on  the  left. 
I  then  announced  that  the  Hippocratic  succussion  would  occasion 
the  sound  of  fluctuation :  and  this  was  found  most  distinctly  to 
be  the  case,  on  trial.     Pectoriloquy  continued  to  be  very  distinct 

*  This  case  affords  another  proof  of  the  cicatrization  of  tuberculous  cavities, 
and  also  of  their  conversion  into  fistula?. — Author. 


548  PNEUMOTHORAX. 

between  the  clavicle  and  second  rib,  and  also  in  the  supra-spinal 
fossa  of  the  left  side.  In  consequence  of  these  observations  I 
caused  the  following  addition  to  be  made  to  the  diagnosis  for- 
merly recorded :  Pleurisy  and  pneumothorax  of  the  left  side  pro- 
duced by  the  discharge  of  a  softened  tubercle  into  the  cavity  of  the 
pleura.     The  patient  died  on  the  following  night. 

Dissection  twenty-four  hours  after  death. — Upon  puncturing 
the  left  side  of  the  chest,  a  great  quantity  of  gas,  nearly  free 
from  smell,  made  its  escape  with  a  hissing  noise  ;  and  upon  laying 
it  open,  the  cavity  of  the  pleura  appeared  half-empty,  the  lung 
being  compressed  upwards  and  backwards  and  reduced  to  less 
than  one-third  its  natural  size.  The  surface  of  the  pleura  was 
here  and  there  of  a  punctuated  red,  and  its  cavity  contained 
about  half  a  pint  of  a  transparent  fluid,  slightly  yellowish  and  in- 
termixed with  some  whitish  flakes.  Nearly  the  whole  upper  lobe 
was  closely  attached  to  the  costal  pleura  ;  and  immediately  below 
this  adhesion,  on  a  level  with  the  third  rib,  there  was  an  ulcer  or 
aperture  of  the  size  of  the  nail,  covered  with  a  thick  yellow  mu- 
cus, from  which  a  slight  pressure  forced  out  bubbles  of  air. 
This  opening  was  the  extremity  of  a  very  short  fistulous  canal  of 
the  thickness  of  the  finger,  which  communicated  with  a  vast  ex- 
cavation occupying  a  great  part  of  the  lower  lobe,  and  nearly 
quite  empty.  Into  this  cavity,  which  was  anfractuous  and  lined 
by  a  false  membrane,  two  or  three  bronchial  tubes,  of  the  size  of 
crow  quills,  were  found  to  open.  The  right  lung  adhered 
throughout  to  the  costal  pleura,  and  contained  many  tubercles 
of  the  size  of  cherry-stones. 

Case  XLI. —  Chronic  pleurisy  and  pneumothorax  with  par- 
tial gangrene  of  the  pleura. — A  man,  aged  twenty-two,  became 
affected,  in  the  beginning  of  October,  with  a  severe  catarrh,  which 
he  attributed  to  drinking  cold  water  while  hot.  This  was  followed 
by  a  constant  cough  and  considerable  haemoptysis.  He  went  into 
an  hospital  at  the  end  of  two  months,  and  after  remaining  there 
a  fortnight  and  being  bled,  his  cough  having  become  somewhat 
better,  he  left  it.  Having  had  a  fresh  attack  ten  days  thereafter, 
he  came  into  the  hospital  under  my  care.  At  this  time  he  was 
affected  with  prostration  of  strength,  impeded  respiration,  fre- 
quent cough,  with  viscid,  frothy,  and  somewhat  adhesive  expec- 
toration, and  acute  pain  in  the  whole  right  side  of  the  chest. 
Respiration  was  perfect  over  the  whole  of  the  left  side,  but  was 
not  perceptible  on  the  right,  except  under  the  clavicle,  and  to- 
wards the  roots  of  the  lung,  in  which  point  there  was  a  distinct 
crepitous  rhonchus.  Percussion  gave  a  good  sound  on  the  left 
side  ;  but  this  was  less  clear  on  the  right  side  before,  and  was 
quite  dull  posteriorly.  From  these  signs,  I  made  out  my  dia- 
gnosis— Pleuro-pneumonia  of  the  right  side.     The  patient  was 


PNEUMOTHORAX. 


549 


bled  throe  times,  had  leeches  applied  also  three  times,  and  was 
kept  on  low  diet.  After  a  continuation  of  the  treatment  the  pain 
of  the  side  disappeared,  and  the  respiration  became  freer,  but  the 
patient  did  not  recover  strength,  and  he  was,  further,  attacked 
with  diarrhoea.  Suspecting  the  existence  of  tubercles,  I  caused 
the  patient  to  be  examined  with  the  stethoscope  by  one  of  my 
pupils,  who  detected  pectoriloquy  about  the  right  shoulder-blade. 
1  further  found  at  this  time  that  the  respiration  continued  to  be 
very  indistinct  in  the  right  side,  while  percussion  elicited  from  it 
a  much  clearer  sound  than  from  the  left.  This  fact,  and  the 
additional  sign  of  the  metallic  tinkling,  discovered  at  this  time, 
convinced  me  of  the  existence  both  of  pleuritic  effusion  and 
effused  air  (having  a  communication  with  the  bronchi)  in  the 
right  side  of  the  chest.  This  was  further  confirmed  by  the  noise 
of  fluctuation  produced  by  the  Hippocratic  succussion.  There 
was,  at  this  time,  no  appearance  of  oedema  on  the  right  side  ;  the 
intercostal  spaces  were  not  at  all  enlarged ;  nor  did  the  liver 
appear  to  be  at  all  pressed  downwards  into  the  abdomen.  How- 
ever, as  the  patient  had  lost  scarcely  any  flesh,  and  his  strength 
seemed  rather  oppressed  than  exhausted,  I  entertained  hopes  of 
saving  him  by  the  operation  of  empyema.  Immediately  after 
this  determination,  the  patient  expectorated  a  very  great  quantity 
of  a  very  fetid  pus  quite  different  from  his  usual  sputa  ;  and  this 
was  followed  by  increased  difficulty  of  respiration,  and  other 
symptoms  indicating  a  recent  pneumonic  attack  on  the  left  side. 
The  operation  was  then  performed,  the  incision  being  made  be- 
tween the  fifth  and  sixth  ribs,  (counting  from  above,)  about  their 
middle  ;  but  no  matter  flowed,  although  the  passage  of  air  by  the 
wound  during  respiration  proved  the  penetration  of  the  chest 
by  the  incision.  Shortly  afterwards  he  again  expectorated  a 
large  quantity  of  very  fetid  pus,  and  died  four  hours  after  the 
operation. 

On  examining  the  body  after  death,  the  right  side  of  the  thorax 
appeared  somewhat  smaller  than  the  left.*  Succussion  of  the 
body  produced  the  sound  of  fluctuation,  but  less  distinctly  than 
before  death.  On  puncturing  the  right  side  of  the  chest,  near 
the  junction  of  the  third  rib  with  its  cartilage,  a  large  quantity 
of  extremely  fetid  gas  made  its  escape ;  and,  on  making  a 
puncture  about  the  middle  of  the  fourth  intercostal  space,  a 
very  great  quantity  of  pus  flowed  out :  this  was  very  liquid,  of 
a  slightly  greenish-yellow  color,  and  of  an  intolerable  gangre- 
nous fetor.  The  whole  of  the  fluid  contained  in  this  side  of  the 
chest  amounted  to  about  a  pint-and-half.     The  lung  was  much 

*  This  is  contrary  to  the  usual  slate  of  things  in  hydrothorax  and  empyema. 
In  the  present  ease  it  was  the  consequence  of  an  anterior  attack  of  pleurisy. — 
Author. 


550  PNEUMOTHORAX. 

flattened  towards  the  mediastinum,  being  only  an  inch  thick  at 
its  superior  part ;  it  gradually  enlarged  downwards,  and  at  its 
inferior  margin  was  two  inches  and-a-half  in  width.  The  lung 
had  thus  three  sides  ; — -the  one  internal,  attached  by  means  of 
short  cellular  adhesions  to  the  mediastinum  ;  the  other  anterior, 
of  a  triangular  shape,  and  attached  by  old  cellular  adhesions  to 
the  sterno-costal  pleura ;  and  the  third  external,  separated  from 
the  ribs  by  a  space  nearly  four  fingers'  breadth  wide,  which 
formed  the  inner  wall  of  the  excavation  which  had  contained  the 
effusion.  This  excavation  (of  which  the  ribs  and  diaphragm 
formed  the  remaining  boundaries)  was  completely  lined  by  a  false 
membrane,  of  a  degree  of  consistence  intermediate  between  that 
of  boiled  white  of  egg  and  cartilage,  of  a  pretty  uniform  thick- 
ness of  from  a  line  to  a  line  and  a  half,  and  of  a  pearl-grey  color, 
and  semi-transparent.  It  seemed  composed  of  two  layers,  the 
under  being  firmer  than  the  upper.  About  the  middle  of  the 
fourth  rib  this  membrane  was  pierced  by  a  small  ulcer  of  the  size 
of  the  nail,  which  extended  to  the  rib,  and  had  all  the  characters 
of  one  produced  by  the  detachment  of  a  gangrenous  eschar.  A 
somewhat  similar  ulceration,  but  extending  only  through  the 
false  membrane  and  subjacent  pleura,  was  perceptible  on  the 
external  side  of  the  compressed  lung.  It  had  the  gangrenous 
fetor,  and  was,  obviously,  an  example  of  the  partial  gangrene  of 
the  pleura  and  false  membranes.  On  the  same  exterior  border 
of  the  compressed  lung,  at  its  posterior  margin,  there  were  two 
more  openings,  which  were  found  to  communicate  with  two  large 
tuberculous  excavations  in  the  substance  of  the  lung,  partly 
filled  with  purulent  matter.  On  blowing  into  the  trachea,  air 
made  its  escape  into  the  cavity  of  the  chest,  into  which  these 
fistula?  opened,  yet  we  could  not  detect  the  exact  medium  of  com- 
munication with  the  bronchi.  The  substance  of  the  lung,  though 
flaccid,  was  still  crepitous,  and  contained  some  tubercles.  Upon 
removing  the  lungs,  it  was  evident  that  the  side  of  the  chest  was 
much  shorter  than  natural.  The  diaphragm  was  found  intimately 
adhering  anteriorly  to  the  seventh  rib,  through  two-thirds  of  its 
length,  the  adhesion  sloping  backwards  to  the  ninth  rib,  so  as  to 
leave  on  the  lower  and  posterior  part  of  the  chest,  a  species  of  cul- 
de-sac,  of  not  more  than  two  fingers'  breadth.  This  state  of 
parts  accounted  for  the  result  of  the  operation.  The  incision 
had  penetrated  through  the  diaphragm  into  the  cavity  of  the 
abdomen,  parallel  with  the  upper  surface  of  the  liver.  The  left 
lung  was  of  the  natural  size,  and  contained  in  its  upper  lobe,  a 
cicatrice  of  the  kind  described  in  the  chapter  on  phthisis,  about 
an  inch  in  length,  as  wide  as  the  finger,  and  of  the  thickness  of 
two  lines  in  its  centre.  Around  this  cicatrice  the  pulmonary 
tissue  was  quite  sound  and  crepitous.     A  little  lower,  and  also  in 


METALLIC    TINKLING. 


551 


the  superior  and  posterior  part  of  the  same  lobe,  it  was  indurated 
to  the  degree  of  hepatization,  and  was  granular  when  cut  into. 
The  remainder  of  the  lung  was  crepitous,  but  much  redder  than 
the  right  lung,  and  gorged  with  a  bloody  serum.  It  contained 
some  small  tuberculous  masses  like  the  right  lung.  The  liver 
was  quite  sound,  and  entirely  concealed  beneath  the  false  ribs. 
Between  it  and  the  diaphragm  passed  the  incision  made  in 
operating. 

The  failure  of  the  operation  in  the  above  case  was  inevitable : 
the  same  thing  would  have  happened  if  the  incision  had  been 
made  three  inches  further  back  ;  and  still  more  certainly  had  it 
'  been  made  in  the  place  of  election.  I  am  not  aware  that  this 
operation  has  before  been  frustrated  by  a  similar  obstacle.  I 
apprehend  so  close  an  adhesion  of  the  diaphragm  to  the  pleura 
of  the  ribs  must  be  very  rare.  In  the  present  case  I  conceive  it 
must  be  attributed  to  a  pleurisy  long  anterior  to  that  which  caused 
the  death  of  the  patient.  I  have  met  with  cases  where  the  liver 
ascended  as  high  as  the  fifth  rib,  and  where"  the  diaphragm  lay 
in  juxtaposition  with  the  pleura,  all  the  way  from  its  natural 
attachments  to  this  point,  without  there  being  any  disease  of  the 
lungs  or  pleura.  In  such  cases  an  attack  of  pleurisy  must  have 
produced  the  extensive  adhesion  described  in  the  last  case. 

Sect.  IV. — Of  the  Metallic  Tinkling  in  effusions  into  the  chest. 

The  metallic  tinkling  is  scarcely  ever  found  in  the  simple  hydro- 
pneumothorax,  that  is,  without  communication  with  the  bronchi. 
In  this  case,  neither  the  respiration,  voice,  nor  cough  produces 
this  phenomenon  ;  but  it  sometimes  takes  place  in  another  manner. 
Should  the  patient  happen  to  raise  himself  suddenly  in  bed,  and 
a  drop  of  fluid  fall  from  the  upper  part  of  the  cavity  of  the  pleura 
into  the  fluid  beneath,  it  produces  a  sound  like  that  occasioned 
by  a  drop  of  water,  let  fall  into  a  flask  three  parts  empty  ;  and 
this  sound  is  immediately  followed  by  a  very  distinct  metallic 
tinkling,  of  longer  duration  than  that  produced  in  another 
manner.  (I  shall  give  an  example  of  this  rare  case  at  the  end  of 
the  present  section.)  It  is  by  means  of  the  stethoscope  that 
I  have  heard  this  modification  of  the  tinkling  ;  and  I  am  doubtful 
if  it  could  be  heard  without  it.  A  pretty  exact  idea  of  it  may 
be  obtained  by  applying  the  instrument  to  the  epigastrium  of  a 
person  in  the  erect  position,  while  he  is  swallowing  a  little  water, 
drop  by  drop:  and  sometimes  an  analogous  sound  is  perceived  in 
the  region  of  the  heart,  just  as  the  individual  has  swallowed  his 
saliva. — But  if  the  phenomenon  is  rare  in  the  simple  hydro-pneu- 
mothorax,  it  is  constantly  observable  during  coughing,  speaking, 
and  breathing,  in  the  case  of  a  fistulous  communication  between 


552  PNEUMOTHORAX. 

the  bronchi  and  pleura ;  or  at  least,  the  utricular  buzzing  is  so, 
if  the  tinkling  is  not  fully  developed.  And  indeed  these  are  the 
only  signs  which  enable  us  to  recognize  the  fistulous  communi- 
cation in  question,  in  the  case  of  empyema  and  pneumothorax  : 
and  such  is  their  certainty,  that  this  is  not  augmented  by  the 
co-existence  of  any  other,  not  even  the  sudden  and  repeated 
expectoration  of  a  large  quantity  of  pus,  which  sometimes  takes 
place  in  these  cases,  but  which  may  be  likewise  the  result  of 
a  mere  bronchial  secretion.  The  extent  over  which  the  metallic 
tinkling  and  buzzing  are  perceived,  together  with  the  Hippocratic 
fluctuation,  serve  to  discriminate  the  case  in  question,  from  a  vast 
tuberculous  excavation.  The  Hippocratic  succussion,  no  doubt, 
of  itself  demonstrates  the  nature  of  the  affection  ;  but  even  here, 
the  other  sign  is  highly  important ;  as  we  cannot  be  too  well 
assured  of  the  existence  of  a  disease  so  severe  as  this,  and  which 
has  hitherto,  perhaps,  never  been  recognized  in  the  living  subject. 
This  may  seem  a  bold  assertion  ;  but  T  am  well  assured  of  its 
correctness  ;  and  in  proof  of  this  I  shall  content  myself  with 
referring  to  the  work  of  M.  Bayle.  His  treatise,  which  is 
unquestionably  the  most  accurate  and  full  of  any  that  have  been 
written  on  diseases  of  the  chest,  contains  five  cases  of  pneumo- 
thorax with  serous  or  puriform  effusion  (Cases  XI.  XL.  XLII. 
XLIII.  XLV.)  In  no  one  of  these,  was  the  disease  suspected 
during  life  ;  and  in  two  of  them  (XLII.  and  XLIII.)  the  aeriform 
effusion  does  not  appear  to  have  been  discovered  even  after 
death,  although  the  existence  of  this  appears  clearly  from  the 
dissection. 

And  yet  Bayle  was  a  practitioner  who  carried  the  precision  of 
diagnosis  as  far  as  ever  any  man  did.  Few,  indeed,  have  pos- 
sessed, in  so  eminent  a  degree,  the  qualities  which  constitute  a 
good  practitioner  and  correct  observer.  His  acute  and  penetrat- 
ing genius  was  perceptible  at  first  sight ;  and  a  very  slight 
acquaintance  was  sufficient  to  discover  in  him  a  mind  no  less  cool 
than  comprehensive,  and  a  most  extensive  erudition,  acquired  by 
a  study  of  the  best  writings,  and  by  personal  and  practical 
researches,  pursued  to  an  extent  and  with  an  assiduity  almost 
superhuman.*  Endued  with  a  vast  power  of  attention,  and  with 
patience  which  nothing  could  rebut  or  weary,  application  seemed 
a  part  of  his  natural  character ;  and  no  one  of  his  friends  or  fel- 
low-laborers ever  perceived  that  fatigue,  discouragement,  or 
negligence  made  him,  on  any  occasion,  omit  to  do  all  and  every 
thing  that  was  proper  to  be  done.       Religious,  moreover,  and 

*  From  the  year  1801  to  the  time  of  his  death,  a  periodof  fourteen  years, 
hardly  a  day  passed  in  which  he  did  not  examine  one  or  more  dead  bodies.  He 
took  accurate  notes  of  all  his  dissections,  as  well  as  of  the  diseases  of  which  the 
individuals  had  died. — Author. 


METALLIC    TINKLING. 


553 


stedfast  in  his  principles  even  to  severity,  from  a  mere  sentiment 
of  duty  he  attended  as  carefully  to  the  patients  who  held  out  no 
prospect  of  supplying  him  with  information,  as  to  those  whose 
cases  were  the  most  curious  and  interesting  ;  and  yet  in  the  in- 
stances now  under  consideration,  he  did  not  discover  the  disease ; 
and  even  in  two  of  them  he  seems  to  have  quite  overlooked  the 
pneumothorax,  after  death,  although  this  appears  clearly  from 
his  own  descriptions  to  have  been  present.  The  fact  is,  that  with 
the  sole  indications  supplied  by  the  general  symptoms,  and  by 
percussion,  it  is  hardly  possible  to  discover  pneumothorax  during 
life  ;  and  when  this  has  been  the  case,  the  air  may  easily  escape 
notice  upon  examination  of  the  body. 

In  some  instances  wherein  I  have  had  the  attendance  of  several 
of  my  medical  brethren,  while  verifying  by  dissection  the  stetho- 
scopic  indications,  I  found  that  some  of  them  were  of  opinion  that 
the  preternatural  or  tympanitic  resonance,  on  percussion,  is  of 
itself  sufficient  to  point  out  pneumothorax.  This  might  certainly 
be  so,  at  least  in  some  extreme  cases ;  but  I  am  doubtful  if  such 
a  thing  ever  actually  occurred.  Bayle  employed  percussion  in 
the  case  of  all  his  patients  ;  and  the  five  above  mentioned  had 
been  subjected  to  the  same  trial.  On  a  former  occasion  I  related 
a  case  (Case  XV.)  in  which  this  physician  did  detect  pneumo- 
thorax by  means  of  the  co-existence  of  the  tympanitic  sound  and 
the  dilatation  of  the  chest :  but  this  was  in  the  dead  body  ;  and 
we  know  that  percussion  affords  much  more  marked  results  in 
the  case  of  a  subject  stretched  on  the  table  of  a  dissecting  room, 
than  in  that  of  a  living  body  in  bed.  The  same  thing  is  true  of 
the  inequality  of  size  in  the  two  sides  of  the  chest,  which  is  very 
perceptible  *in  the  naked  body,  though  hardly  discoverable  in 
a  person  with  merely  a  shirt  on.*  Neither  Avenbrugger  nor 
Corvisart  mention  pneumothorax  ;  and  yet  both  of  them  must 
have  seen  examples  of  it,  especially  the  latter,  both  in  the  living 
and  dead  body :  for  this  disease  is  by  no  means  so  rare,  as  to  make 
it  possible  to  be  in  the  habitual  examination  of  the  living  and 
dead  body,  for  several  years  together,  without  meeting  cases  of 
it.  Even  in  the  instance  of  the  tympanitic  sound  combined  with 
dilatation  of  the  side,  there  still  remains  the  uncertainty  whether 
the  larger  side  is  really  preternaturally  dilated,  or  the  other  is 
contracted  in  consequence  of  pleurisy.  And  when  the  dilatation 
of  the  side  either  does  not  exist  or  is  not  perceived,  we  will 
be  liable  to  a  more  serious  error,  that,  namely,  of  considering  the 
side  which  sounds  well,  as  healthy,  and  the  other  as  the  seat  of 
pneumonia  or  pleurisy  :  and,  in  fact,  this  is  the  conclusion  come 

*  The  argument  here  used  is  invalid  :  as,  assuredly,  no  physician  would  fail  to 
examine  the  naked  chest  under  such  circumstances  as  those  contemplated  in  the 
case  in  question. —  Transl. 

70 


554  PNEUMOTHORAX. 

to  by  all  the  physicians  to  whom  I  showed  my  cases  of  pneumo- 
thorax, previously  to  communicating  to  them  the  indications  of 
the  stethoscope.  The  only  instance  wherein  percussion  will 
supply  positive  results,  is  that  in  which  air  and  liquid  co-exist ; 
and  these  results  will  be  obtained  by  that  method  of  which  I 
have  shown  the  inefficacy  in  the  case  of  simple  hydrothorax  or 
pleurisy, — I  mean,  percussion  exercised  in  different  positions  of 
the  chest.  In  these  circumstances,  the  gas  rising  always  to  the 
part  of  the  cavity  which  is  superior,  the  sphere  of  the  dead 
sound  will  vary  with  each  posture  of  the  patient.  But  indepen- 
dently of  the  mistakes  which  might  still  be  occasioned  in  such 
cases  by  adhesions  of  the  lungs,  the  great  inconvenience  of  such 
a  method,  both  to  the  patient  and  physician,  will  prevent  its 
being  used,  except  where  the  nature  of  the  affection  is  already 
suspected. 

If  the  cases  observed  by  Bayle  and  those  which  must  have 
been  seen  by  Avenbrugger  and  Corvisart,  had  come  before  a 
physician  acquainted  with  the  practice  of  mediate  auscultation, 
they  must  of  necessity  have  been  recognized.     The  metallic  tink- 
.  ling  by  itself  would,  in  several  cases,  have  pointed  out  the  whole 
complicated  character  of  the  disease,  viz.  the  pneumothorax,  the 
extravasated  fluid,  and  the  fistulous  opening  between  the  pleura 
and  bronchi.     In   the  cases  in  which  this  communication  did  not 
exist,  the  absence  of  the  respiratory  sound  would  have  led  him  to 
percuss   the  chest ;  and  the  results  obtained   from  percussion, — 
pointing  necessarily  either  to  pneumothorax  or  emphysema  of  the 
lungs, — would   have  led  to  the  exploration  of  the  whole  chest, 
and  consequently  to  the  discovery  of  the  actual  disease.     Having 
proved  the  affection  to  be  pneumothorax,  he  would  have  ascer- 
tained whether  it  was  simple  or  complicated  with  liquid  effusion, 
by  means  of  the  Hippocratic  succussion.     I  am  far  from  wishing 
to  throw  blame  on  the  excellent  observers  just  named,  for  what 
they  did  not  do.     I  have  been  merely  desirous  of  showing   that 
various  methods  may  be  combined,  with  great  advantage,  to  obtain 
the  end  in  view ;  and  that  this  combination  is  infinitely  more  cer- 
tain in  its  results  than  the  method  which  has  been  hitherto  exclu- 
sively employed. 

Case  XLII. — Pneumothorax  and  subacute  pleurisy,  in  a 
phthisical  subject. — A  man,  aged  twenty-nine,  caught  a  severe 
catarrh  from  exposure  to  much  cold  in  the  beginning  of  October, 
1818,  which  he  neglected,  as  he  had  done  a  cough  with  which  he 
had  been  affected  in  the  preceding  spring.  This  catarrh,  after  a 
few  weeks  was  followed  by  spitting  of  blood  for  several  days, 
and,  subsequently,  by  a  continual  cough,  dyspnoea  and  emacia- 
tion..  On  the  5th  of  February,  1819,  he  came  into  the  Necker 
Hospital.      At  this  time  he  was  evidently  in  a  confirmed  con- 


METALLIC    TINKLING.  555 


sumption — being  affected  with  great  emaciation,  frequent  cough, 
yellow  opaque  sputa,  dyspnoea,  diarrhoea,  and  pectoriloquy  below 
both  clavicles,  evident  on   the   left,  doubtful   on  the  right   side. 
Things  continued  much  in  the  same  way  until  the  17th,  when  at 
the   hour  of  visit  I  found    the   patient  agitated   and    exhausted, 
with  quicker  pulse  and  hot  skin.     Presuming  that  a  slight  pneu- 
monia had  supervened  to  the  tuberculous  affection,  I  explored 
the  chest  with  the  stethoscope.     The  respiration  was  inaudible 
on  the  left  side  anteriorly  and  laterally,  although  the  chest  was 
fully  dilated  at  each  inspiration  :  behind,  over  the  roots  of  the 
lungs,  it  was  perceptible,  but  in  a  less  degree  than  natural ;  per- 
cussion yielded  a  good  sound  every  where.     Having  the  cylinder 
applied  to  the  chesf  below  the  left  clavicle,  as  the  patient  placed 
himself  in  a  sitting  posture,  I  heard  distinctly  a  sound  like  that 
produced  by  a  drop  of  liquid  let  fall  into  a  flask  containing  a 
very  small  quantity  of  water ;  and  this  sound  was  followed  for 
a  second,  by  a  tinkling  such  as  is  occasioned  by  striking  a  glass 
with   a   pin.     Neither  the    voice,    cough,  nor   respiration,   was 
attended  by  any  sound  of  the  same  kind.     The  respiration  was 
good  on  the  right  side,  but    was  accompanied  by  a  rhonchus, 
which  was  sibilous,  sonorous,  and  mucous,  in    different  points. 
The  whole  of  this  side  sounded  much  less  than  the  other ;  indeed, 
the  sound  was  comparatively  quite  dull.     These  signs  pointing  , 
out,  with  certainty,  the  existence  of  pneumothorax  on  the  left 
side,  I  had  the  patient  undressed,  in  order  to  see  if  this  side  was 
dilated :  some  difference  seemed   observable,  particularly  on  the 
lower  part,  but  it  was  so  slight  that  we  could  be  by  no  means 
certain  of  it.     Suspecting  from  the  metallic  tinkling  that  there 
existed   a  small  effusion   of  liquid  along  with  the  pneumothorax, 
I  applied  the  test  of  succussion,  and  heard,  both  by  the  stetho- 
scope and  the  naked  ear,  the  sound  of  fluctuation,  apparently  in 
the  left  side.     I  added,  in  consequence,  to  my  diagnosis— Pneu- 
mothorax, with  a  small  effusion  of  pus,  in  the  left  side  of  the 
chest ;  and  subjoined  an  opinion,  founded  on  the  absence  of  the 
metallic  tinkling  during  coughing  and  speaking,  that  the  effusion 
did  not  originate  in   the  rupture  of  a  softened  tubercle  into  the 
pleura  and  bronchi.     Seeing  no  other  means  of  relieving  the 
patient,  I  proposed  the  operation  of  empyema.     This,  however, 
was  not  performed,  as  he  died  the  same  day,  although  at  the  hour 
of  the  visit  there  did  not  seem  any  thing  indicative  of  so  sudden 
a  termination  of  the  disease. 

On  examining  the  body  after  death,  the  left  side  of  the  chest 
appeared  to  me  evidently  enlarged ;  but  this  was  doubted  by 
some  of  the  persons  present.  On  percussion  it  certainly  yielded 
a  much  clearer  sound  than  the  other,  and  succussion  of  the  trunk 
produced   the  noise  of  fluctuation.     On  puncturing  the  thorax 


556  PNEUMOTHORAX. 

with  a  scalpel  on  the  left  side,  a  nearly  inodorous  gas  continued 
to  escape,  with  a  hissing  noise,  for  nearly  a  minute  ;  and,  on 
opening  it,  it  was  found  three-fourth  parts  empty,  the  lung  being 
found  only  one-third  its  natural  size,  and  compressed  towards 
the  mediastinum,  but  without  adhering  to  it.  In  the  same  cavity 
there  was  nearly  a  pound  of  a  liquid  resembling  whey,  of  a 
whitish  color,  turbid,  and  containing  portions  of  yellowish  half- 
concrete  albumen  :  it  was  quite  covered  with  transparent  bubbles, 
exactly  resembling  those  produced  by  agitating  or  blowing  into 
soapy  water.  The  whole  of  the  lung,  on-  this  side,  was  covered 
with  an  irregular  albuminous  membrane,  which  in  several  places 
greatly  resembled  an  omentum  moderately  loaded  with  fat.  In 
the  top  of  the  superior  lobe  there  were  two  excavations,  con- 
taining only  a  soft  tuberculous  pus,  and  each  capable  of  holding 
a  walnut.  But  these  were  lined  with  a  double  membrane,  and 
communicated '  with  bronchial  tubes.  The  whole  lung  was  filled 
by  tubercles,  in  every  stage  of  their  progress.  The  upper  lobe 
of  the  right  lung  adhered  to  the  pleura,  and  contained  a  series  of 
large  tuberculous  excavations,  partly  empty,  and  all  lined  by  the 
semi-cartilaginous  membrane.  This  lobe  further  contained  many 
immature  tubercles  ;  the  other  lobes  were  sound.* 

In  reviewing  the  series  of  signs  detailed  in  this  chapter,  we  per- 
ceive that  pneumothorax  is  not  only  of  easy  recognition,  but  that 
'  each  of  its  varieties  may  be  readily  distinguished  from  the  others. 
These  varieties,  in  a  diagnostic  point  of  view  may  be  reduced  to 
the  following :  1.  simple  pneumothorax;  2.  pneumothorax  with 
liquid  effusion  ;  3.  pneumothorax  with  liquid  effusion  and  fistu- 
lous opening  between  the  bronchi  and  pleura.  In  the  first  of 
these  cases,  the  affected  side  sounds,  at  least,  well,  and  sometimes 
is  preternaturally  sonorous  ;  while  the  respiration  is  not  at  all 
perceptible.f  When  pneumothorax  is  combined  with  liquid 
extravasation,  the  same  signs  exist,  with  these  in  addition  :  the 
most  dependent  parts  of  the  chest  yield  a  dull  sound,  and  these 
parts  vary  with  the  position  of  the  patient ;  and  the  Hippocratic 
succussion  gives  the  sound  of  fluctuation.  In  the  third  variety, 
to  all  the  preceding  signs  we  have  to  add  the  metallic  tinkling  or 

*  In  the  eight  cases  of  pneumothorax  ahove  detailed,  the  disease  appears  to 
have  equally  affected  the  two  sides  of  the  chest ;  in  two  cases  formerly  given 
(Cases  XV.  and  XVI.)  the  site  of  the  affection  was  the  left  side  :  the  result  of  the 
whole  being  six  on  the  left  and  four  on  the  right  side.  The  collation  of  all  the 
known  cases  of  pneumothorax  (forty-nine  in  number)  by  M.  Reynaud,  gives  thirty 
two  on  the  left,  and  seventeen  on  the  right.  (Journ.  Hebdom.  April,  J830.)  It 
would  thus  appear  that  pneumothorax— the  reverse  of  tubercles,  with  which  it 
is  nevertheless  almost  always  conjoined — is  generally  more  frequent  on  the  left 
than  on  the  right  side.  I  do  not,  however,  think  that  the  number  of  our  obser- 
vations are  yet  sufficient  to  justify  our  establishing  an  absolute  rule  as  to  the  rela- 
tive frequency  of  site  of  this,  disease. — (M.  I.) 

t  We  must  here  except  tile  rare  casg,  formerly  mentioned,  where  the  puerile 
respiration  of  the  sound  lung  is  heard  through  the  diseased  side. — Author. 


METALLIC    TINKLING.  557 

amphoric  resonance,  which  commonly  alternate.*  The  two  first 
varieties  cannot  be  confounded  with  any  other  affection  ;  the  last 
presents  signs  very  analogous  to  those  afforded  by  a  vast  tuber- 
culous excavation  nearly  empty.  But  even  here  a  mistake  is  v^ry 
unlikely.  In  the  pulmonary  excavation,  we  have  some  remains 
of  pectoriloquy  ;  the  sphere  of  the  tinkling,  amphoric  buzzing, 
and  tympanitic  resonance  on  percussion,  is  very  circumscribed  ; 
and  there  is  no  fluctuation  on  succussion,  while  the  cough  some- 
times occasions  a  guggling  or  slight  fluctuation,  which  is  never 
the  case  in  pneumothorax.! 

Treatment. — The  exact  diagnosis  of  pneumothorax,  and 
of  each  particular  variety  of  it,  must  not  be  considered  as  a 
matter  of  purely  speculative  knowledge,  or  as  useful  only  in 
respect  of  the  prognosis  of  the  disease.  ,  It  is  extremely  probable 
as  has  been  remarked  by  HewsonJ  and  Rullier,^  that  simple 
pneumothorax  is  the  case  which  holds  out  most  prospect  of  suc- 
cess from  the  operation  of  puncturing  the  chest.  •  This  opinion  is 
corroborated  by  an  observation  of  Riolan,  who  informs  us  that 
he  had  several  times  seen  the  operation  of  paracenteses  success- 
fully performed  on  patients  considered  as  affected  with  dropsy, 
but  from  whose  chests  only  air  made  its  escape.  ||  In  cases  of 
this  kind,  the  puncture  with  the  trocar  would  unquestionably  be 
preferable  to  incision.  But  I  would  here  remark,  that,  ex- 
clusively of  the  great  infrequency  of  the  simple  pneumothorax, 
I  think  it  must  be  generally  considered  as  of  no  great  severity, 
the  gas  being  more  readily  absorbed  than  the  liquid  effusion. 

*  The  precise  period  of  occurrence  of  this  last  variety  is  commonly  indicated 
by  a  particular  set  of  symptoms  formerly  noticed,  and  to  which  M.  Louis  has 
more  particularly  called  attention  ;  (Rcch.  sur  la  Plith.  p.  445  ;)  viz.  sudden  acute 
pain  on  one  side  of  the  chest,  accompanied  with  a  strong  sense  of  suffocation 
and  great  anxiety.  Sometimes,  however,  the  pain  and  suffocation  arc  not  suf- 
ficiently marked  to  attract  the  attention  of  the  patient  or  his  medical  attendant; 
and  these  symptoms  are,  consequently,  only  of  value  when  they  harmonize  with 
the  stethoscopic  signs. — (M.  L.)  i 

t  I  here  subjoin  a  brief  summary  of  the  principal  diagnostic  signs  of  pneumo- 
thorax,, with  the  estimated  value  of  each,  from  the  very  valuable  Treatise  on 
Pneumothorax  by  Dr.  Houghton,  in  the  Cyclopaedia  of  Practical  Medicine.  The 
young  practitioner  will  find  his  advantage  in  referring  to  this  recapitulation  after 
perusing  the  text  of  our  author  and  the  various  notes  which  have  been  appen- 
ded to  this.  "1.  The  sensation  of  something  giving  way  in  the  chest,  and  of 
air  entering  the  pleural  cavity  :  very  valuable,  but  often  absent  or  unnoticed. 
2.  In  a  phthisical  individual,  the  sudden  supervention  of  overwhelming  dyspnoea 
and  pain  :  rarely  absent,  therefore  very  valuable}  still  more,  so  if  succeeding  last 
sign.  3.  Comparison  of  auscultation  and  percussion.  Nullity  of  respiration 
over  one  side,  together  with  tympanitic  clearness  of  sound,  which  below  ter- 
minates abruptly  in  complete  dullness:  \f  accurately  established,  amounting  to 
positi  re  certainty,  but  sometimes  not  easy  to  establish  :  JEgapliony  reire.  4.  Fluc- 
tuation on  succussion  :  positive  certainty,  but  should  be  unquestionably  verified. 
5.  Metallic  tinkling  :  positive  certainty,  but  should  be  unquestionably  verified. — 
Truiisl . 

X  Med.  Obs.  and  Inq.  v.  iii.  p.  72.         §  Diet,  de  Sc.  Med.  art.  Empycme. 

||  Enchyrid.  Anat.  1.  iii.  chap.  ii. 


558  PNEUMOTHORAX. 

I  think  myself  justified,  at  least  in  drawing  this  conclusion  from 
the  frequency  of  gaseous  effusions  in  other  situations,  which  dis- 
appear spontaneously,  and  frequently  in  the  course  of  a  few  days 
or  «even  hours.  Of  this  kind  is  the  pneumo-pericardium,  and 
the  various  kinds  of  pneumcwthrosis,  particularly  that  of  the 
knee,  which  so  frequently  arises  during  the  convalescence  from 
articular  rheumatism,  as  well  as  in  other  circumstances.  On  this 
account,  before  proceeding  to  puncture  the  chest,  we  ought  to 
endeavor  to  excite  absorption  by  aromatic  and  spirituous  fric- 
tions, and  by  the  internal  use  of  slight  tonics. 

Pneumothorax  complicated  with  liquid  effusion  and  still  more 
with  pulmonary  fistula,  is  a  case  of  a  most  serious  nature,  and 
leaves  little  hope  of  a  cure  being  effected.  This,  however,  must 
not  be  considered  as  quite  impossible,  even  in  the  severest  cases. 
I  formerly  proved  the  possibility  of  the  cicatrization  of  tuber- 
culous excavations ;  and  the  observations  of  Bacqua,  Jaymes 
and  Robin,  (Journ.  Gen.  de  Med.,  1813,)  to  which  I  could  add 
a  more  recent  case  of  the  same  kind,  (I  mean  cases  where  the 
patients  recovered  after  the  operation  of  empyema,  although  the 
injections  thrown  into  the  wound  were  found  to  be  discharged 
by  the  mouth,)  sufficiently  prove,  that,  even  in  such  cases,  we 
may  adopt  the  mode  of  cure  just  named,  with  some  prospect  of 
success.  Even  nature  by  herself  may  sometimes  overcome,  more 
or  less  completely,  a  lesion  of  the  kind  in  question,  as  I  shall 
show  in  a  case  to  be  detailed  at  the  end  of  the  present  chapter. 
I  saw  another  case  of  the  same  kind,  in  1820,  in  a  man  who  came 
on  horseback  thirty  leagues,  to  consult  me.  In  this  person  there 
was  every  sign  of  the  complication  in  question  existing  on  the 
right  side.  The  disease  was  of  two  years'  standing,  and  nature 
had  already  made  considerable  progress  towards  a  cure,  as  the 
affected  side  was  evidently  contracted.  I  ascertained  in  1824 
that  this  man  was  still  alive,  and  attending  to  hjs  .  business  :  he 
was  improved  in  health,  though  still  an  invalid.  It  cannot  be 
denied,  however,  that  cases  of  this  kind  are  exceptions  to  the 
general  rule ;  and  that  the  two  last  varieties  of  pneumothorax 
afford  much  less  chance  of  success  from  the  operation  of  empyema, 
than  the  simple  effusion,  whether  of  air  or  liquid.  Accordingly, 
I  think  that  we  ought  never  to  attempt  this  operation  in  such 
cases,  unless  there  is  imminent  risk  of  suffocation,  or  rapidly 
increasing  emaciation  and  debility ;  and  never  after  the  long 
continuance  of  the  disease,  unless  the  lung  on  the  sound  side 
gives  no  indication  of  tubercles.  In  every  other  case,  I  think 
that  we  ought  to  content  ourselves  with  supporting  the  patient's 
strength,  promoting  absorption  by  the  means  formerly  mentioned, 
and  by  a  regimen  regulated  according  to  the  state  of  the  diges- 
tive functions, — neither  too  rigid  nor  too  analeptic. 


METALLIC    TINKLING. 


559 


Case  XLIII. — Pleurisy  with  contraction  of  the  chest,  and 
pulmonary  fistula  opening  outwards. — A  boy,  twelve  years  of 
age,  was  attacked  with  a  severe  pectoral  affection,  marked  by 
violent  cough,   acute  pain  of  the  side,  dyspnoea  and  fever,   fol- 
lowed, in  a  few  days,  by  considerable  haemoptysis,  and,  subse- 
quently,  by  expectoration  of  a  purulent  fluid  in  great  quantity. 
The  disease  then  took  a  chronic  form ;   and  in  the  course  of  a 
few  months,  an  abscess  pointed  externally  between  the  cartilages 
of  the  seventh  and  eighth  ribs,  which,  when  open,  discharged  a 
considerable  quantity  of  pus.     Since  then  (now  six  years)  the 
aperture  had  remained  fistulous,  daily  discharging  one  or  two 
spoonsful  of  pus.     Occasionally,   during  a  temporary  obstruction 
of  the  orifice,  the  expectoration  of  this  patient  had  become  aug- 
mented, and  the  sputa  had  been  then  always  perfectly  like  the 
pus  usually   evacuated  from  the  abscess.     At  this  period  I  exa- 
mined the  boy.     He  was  much  emaciated,  but  not  like  one  wasted 
by   consumption,   the   emaciation   being  confined  rather  to  the 
bones  and  muscles,  than  to  the  cellular  membrane.     He  was  ex- 
tremely small  for  his  age.     The  left  side  of  the  chest  was  at 
least  one-third  narrower  than  the  right,  and  this  contraction  was 
not  remarkable  at  the  inferior  margin  and  in  the  antero-posterior 
diameter.     On  examining  the  thorax  the  whole  right  side  yielded 
a  clear  sound  on   percussion,  but  one  less   distinct  on   the  left. 
The   respiration  was  quite   distinct  over  the   whole  of  the  right 
side ;  it  was  very  indistinct  in  the  superior   part  of  the  left  side, 
and  quite  inaudible  in  the  whole   inferior  portion.     Pectoriloquy, 
also,  existed  in  the  lateral  and  superior  parts  of  the  same  side. 

From  circumstances  of  the  above  case  it  is  evident  that,  in  the 
first  instance,  the  maturation  of  one  ok  more  tuberculous  masses 
had  been  attended  by  an  acute  pleurisy ;  that,  although  the 
tubercles,  when  softened,  had  been  expectorated,  yet  that  a  com- 
munication between  the  remaining  excavations  and  the  pleura 
had  been  subsequently  established,  which  had  given  rise  to  the 
external  abscess.  The  eventful  formation  of  a  fibro-cartilaginous 
membrane  had  produced  the  union  of  the  lungs  and  pleura,  and 
the  consequent  contraction  of  that  side  of  the  chest.  As  this 
patient  has  already  lived  so  long  with  this  affection,  it  is  probable, 
if  the  expectoration  does  not  greatly  increase,  that  he  may  sur- 
vive a  long  time  yet.  Willis  relates  a  case  similar  to  the  above, 
in  so  far  as  regards  the  possibility  of  a  cure  after  the  operation  of 
empyema.  In  this  case  the  fluctuation  of  the  liquid  effused  into 
the  chest  was  heard.  The  patient  was  cured,  but  the  wound 
produced  by  the  operation  remained  fistulous.* 

*  Op.  Om.  >Sect.  I.  cap.  xiii.  lib.  ii.     De  Medicament.  Operat.  p.  215. 


560  DOUBLE    PNEUMOTHORAX. 


Sect.  V. — Of  Double  Pneumothorax. 

It  is  by  no  means  very  uncommon  to  perceive  the  escape  of  a 
small  quantity  of  air  (discovered  by  the  hissing  sound)  from  each 
side  of  the  pleura,  on  opening  the  chest  in  the  dead  body.  Ac- 
cumulations of  air  of  this  kind  are  commonly  small  in  quantity, 
are  usually  combined  with  a  small  portion  of  liquid,  and  must 
be  considered  as  the  product  of  the  changes  immediately  pre- 
ceding death.  But  double  pneumothorax  occurs  under  other 
circumstances;  though  it  is  certainly  extremely  rare.  I  shall 
here  give  a  brief  note  of  the  only  two  cases  I  am  acquainted  with. 
In  the  year  1814  M.  Recamier  had  under  his  care  in  the  Hotel 
Dieu,  a  man  about  sixty  years  old,  who  came  into  the  hospital 
laboring  under  an  attack  which  resembled  asthma.  The  face 
was  swollen,  the  lips  and  cheeks  purple,  the  feet  cold  and  ccde- 
matous,  the  pulse  small,  hard  and  intermittent,  the  action  of  the 
heart  strong  and  irregular,  with  extreme  dyspnoea  and  distressing 
cough.  The  chest  was  large  and  rounded,  and  yielded  a  good 
sound  on  percussion.     The  patient  died  after  a  few  days. 

A  great  quantity  of  air  made  its  escape  on  puncturing  each 
side  of  the  chest.  The  lungs  were  compressed  against  the  spine, 
and  did  not  exceed  the  size  of  the  hand ;  they  were  dry  on  the 
surface,  but  were  in  other  respects  sound.  The  pleura  was 
healthy,  but  was  detached  in  many  points  from  the  ribs  by  bub- 
bles of  air  contained  in  the  subjacent  cellular  substance.  The 
heart  was  slightly  hypertrophied  and  dilated.  I  myself  saw  a 
similar  case  in  1816  in  the  person  of  a  patient  in  the  earlier  stages 
of  phthisis,  who  was  suddenly  seized  with  extreme  dyspnoea  and 
frequent  faintings,  and  died  three  days  thereafter.  The  lungs 
were  found  reduced  to  one-third  their  natural  size,  and  com- 
pressed upon  the  mediastinum.  Each  cavity  of  the  pleura  con- 
tained about  a  pint  and  half  of  limpid  serum  and  an  equal  volume 
of  gas.  The  lungs  contained  only  a  small  number  of  miliary  tu- 
bercles. Cases  of  this  kind  are  beyond  all  the  resources  both  of 
nature  and  art.* 

*  LITERATURE  OF  PNEUMOTHORAX. 

1803.  Itard,  (E.  M.)  Diss,  sur  le  Pneumothorax.     Par.  8vo. 

1830.  Piorry,  Diet,  des  Sc.  M.     (Art.  Pnmmato-4korax;)     t.  xliii.  8vo.  Par. 

1827.  Chomel,  Diet,  de  Med.     (Art.  Pneumatoses)     t.  xvii.     Pur. 

1834.  Houghton,  Cye.  of  Praet.  Med.     (Art.  Pneumothorax.)     vol.  iii. 

Besides  the  above  treatises,  there  are  numerous  cases  recorded  in  the  periodi- 
cal literature  of  this  and  oilier  countries  since  the  distinct  recognition  of  the  dis- 
ease by  Laennec;  also  several  others  incidentally  noticed,  particularly  hy  surgi- 
cal writers,  before  the  nature  of  the  affection  was  understood.  In  a  considerable 
proportion  of  the  cases  published  under  the  name  of  Empyema,  pneumothorax 
has  been  a  concomitant. —  Transl. 


ACCIDENTAL    PRODUCTIONS    IN    THE    PLEURA.  561 

CHAPTER  V. 

OF    ACCIDENTAL    PRODUCTIONS    DEVELOPED    IN    THE    PLEURA. 

Sect.  I. — Of  Accidental  Productions  which  are  usually  accom- 
panied ivith  liquid  effusion. 

The  accidental  productions  of  the  pleura  which  are  commonly 
accompanied  by  a  liquid  extravasation  or  chronic  inflammation, 
are  chiefly  of  a  cancerous  or  tuberculous  kind.  The  first  are 
most  commonly  of  the  medullary  species  of  cancer.  They  ad- 
here strongly  to  the  membrane,  and  consist  of  masses  of  variable 
size,  but  rarely  larger  than  an  almond.  They  are  usually  sur- 
rounded by  increased  redness  of  the  pleura,  produced  by  an  in- 
finity of  finely  ramified  vessels ;  and  we  sometimes  observe  little 
black  lines  stretching  from  their  base  over  the  adjoining  pleura, 
produced  by  melanose  matter.  Tumors  of  this  kind  are  seldom 
numerous. — On  the  other  hand,  the  tubercles  of  the  pleura  exist 
usually  in  very  great  numbers,  and  vary  in  size  from  that  of  a 
millet  seed  to  a  hemp  seed.  They  are  placed  very  close  together, 
and  are  frequently  connected  by  means  of  a  very  soft  semi-trans- 
parent false  membrane.  When  we  have  an  opportunity  of  ob- 
serving this  species  of  production  near  the  period  of  its  forma- 
tion, we  can  sometimes  scrape  off  the  false  membrane,  and  the 
greater  number  of  the  tubercles  along  with  it;  a  circumstance 
which  seems  to  prove  these  bodies  to  be  developed  in  this  mem- 
brane, and  to  appertain  to  it  rather  than  the  pleura.  At  an  ul- 
terior stage,  the  false  membrane  is  no  longer  perceptible,  having 
become  organized  and  cemented  with  the  pleura,  which  then 
appears  as  if  thickened.  The  tubercles,  in  this  case,  are  ex- 
tremely adherent,  and  seem  implanted  in  the  Aery  substance  of 
the  pleura.  Sometimes  the  tubercles  are  in  their  first  stage,  that 
is,  semi-transparent,  greyish,  or  almost  colorless ;  at  other  times 
they  are  in  the  second  stage,  or  yellow  and  opaque.  I  have 
never  found  them  softened.  The  intermediate  portions  of  the 
pleura  are  frequently  very  red,  and  even  injected  very  distinctly 
with  blood-vessels.  In  this  state  the  pleura  has  very  much  the 
appearance  of  the  skin  in  certain  miliary  eruptions.  Although, 
as  I  have  said,  the  tubercles  most  commonly  originate  in  a  false 
membrane,  they  may,  nevertheless,  be  developed  in  the  very  sub- 
stance of  the  serous  membrane,  and  indeed  in  any  membrane, 
without  any  sign  of  preceding  inflammation  discoverable  before 
or  after  death.  We  occasionally,  also,  meet  with  another  species 
of  granulations  on  the  surface  of  the  pleura,  consisting  of  small, 
71 


562  ACCIDENTAL    PRODUCTIONS    IN    THE    PLEURA. 

opaque,  white  grains,  of  a  flattened  form,  placed  close  to  one 
another,  and  resembling,  from  their  great  density,  the  fibrous 
membranes.  This  species  of  eruption,  which  is  likewise  accom- 
panied with  thickening  of  the  pleura,  appears  to  me  to  be  the 
consequence  of  an  imperfect  process  of  organization  in  a  granu- 
lated false  membrane  of  the  kind  formerly  described.*  The  two 
last-mentioned  productions  are  not  often  met  with  on  the  pleura ; 
but  are  extremely  common  on  the  peritoneum.  Bichat  first  no- 
ticed these  bodies,  but  he  does  not  seetn  to  have  well  under- 
stood their  nature.  They  are  always  attended  with  hydrothorax. 
This  is  usually  the  case  with  the  cancerous  productions  also  ; 
but  by  no  means  so  constantly  as  the  others.  In  all  cases,  the 
effused  serum  is  almost  always  red  or  bloody.  When  the  ex- 
travasation has  taken  place,  it  will  always  be  discoverable  by  the 
stethoscope ;  but  this  instrument  affords  us  no  aid  in  discovering 
the  primary  cause  of  the  effusion :  we  can  in  this  respect  derive 
assistance  from  the  general  symptoms  only. 

Sect.  II. — Of  Accidental  Productions  of  a  solid  kind. 

The  pleura,  like  all  the  serous,  and  even  mucous  membranes 
of  the  body,  may  be  so  altered  in  its  nature  as  to  secrete  tuber- 
culous or  cancerous  matter  in  place  of  its  natural  fluid.  This 
matter  may  be  formed  in  such  quantity  as  completely  to  fill  one 
of  the  cavities  of  the  chest  compressing  the  lungs  upon  the  spine. 
This  is  a  very  different  case  from  that  already  mentioned,  of  the 
development  of  tubercles  on  the  surface  of  the  pleura:  in  this 
latter  case  the  tuberculous  matter  is  not  secreted  by  the  pleura, 
but  originates  in  the  false  membranes  of  pleurisy.  Such  morbid 
productions  as  we  are  now  considering  are  very  rare.  There  is 
no  "well-described  case  of  the  kind  on  record  ;  but  I  apprehend 

*  These  are  the  granulations  formed  by  the  rudiments  of  false  membranes, 
(see  note,  Chap,  on  Phthisis)  which  Andral  considers  identical  with  the  grey 
tubercular  granulations.  The  reader  must  judge  whether  there  is  or  is  not,  in 
reality,  some  difference  between  flattened,  white,  opaque  grains,  and  roundish, 
greyish,  or  nearly  colorless,  semi-transparent  grains :  they  are  both  hard. — 
(M.  L.) 

I  have  nowhere  said  that  the  granulations  developed  on  the  free  surface  of 
the  serous  membranes,  and  which  are  nothing  but  rudiments  of  false  membranes, 
were  of  the  same  nature  with  the  grey  granulations  found  in  the  lungs  :  I  have 
said  merely  that  these  pulmonary  granulations  ought  no  longer  to  be  regarded 
as  real  tubercles;  that  we  must  not  consider  as  such,  the  rudiments  of  false 
membranes,  resembling  granulations,  which  occur  in  serous  membranes  in- 
flamed: I  have  compared  these  two  species  of  productions,  not  for  the  purpose 
of  confounding  them  together,  but  to  distinguish  them  both  from  tubercles.  It 
would  be  as  reasonable  to  say  I  have  confounded  the  pulmonary  granulations 
with  the  intestinal  follicles,  because  I  have  also  remarked  that  these  last  have 
also  been  mistaken  for  tubercles,  and  that  they  differ  from  these  bodies  as  much 
as  the  fragments  of  the  pulmonary  lobules  affected  by  grey  induration  and  in  a 
granular  shape,  differ  from  them.— Andral 


ACCIDENTAL    PRODUCTIONS    IN    THE    PLEURA. 


563 


those  scirrhous  masses  mentioned  by  authors  as  filling  one  of  the 
thoracic  cavities  must  be  of  the  kind  in  question.  Boerhaave 
appears  to  have  found  the  medullary  tumor,  or  soft  cancer,  in 
this  situation  in  the  person  of  the  Marquis  of  St.  Aubin.*  Cor- 
visart  met  with  a  case  of  the  same  kind  ;  and  M.  Recamier  found 
in  the  body  of  a  patient,  whom  he  considered  as  affected  with 
empyema,  the  whole  of  one  of  the  cavities  of  the  chest  filled  with 
a  mass  of  tuberculous  matter.  Haller,  as  I  formerly  observed, 
seems  to  have  met  with  a  large  quantity  of  the  matter  of  mela- 
nosis in  the  same  cavity .f  In  two  instances  I  have  myself  dis- 
covered a  considerable  quantity  of  tuberculous  matter  ip  this 
situation.  In  both  these,  the  matter  was  in  different  degrees  of 
consistence.  It  was  most  solid  at  the  bottom  of  the  cavity,  and 
over  the  whole  of  the  surface  of  the  pleura,  on  which  it  formed 
a  layer  of  more  than  an  inch  thick :  the  remainder  of  the  matter 
was  quite  soft,  and  was  contained  in  the  center  of  this  sort  of  sac. 
The  following  case,  communicated  to  me  by  M.  Cayol,  is  a  third 
instance  of  the  same  kind. 

Case  XLIV. — Tuberculous  mass  developed  in  the  pleura. — 
A  negro  child,  six  years  of  age,  entered  the  children's  hospital  in 
1807.  Nothing  respecting  his  previous  history  could  be  ascer- 
tained. At  the  time  of  his  admission,  he  had  a  deep  and  painful 
ulcer  on  the  temple,  constant  diarrhoea,  frequent  dry  cough  unac- 
companied by  dyspnoea,  and  irregular  fever.  He  died,  gradually 
exhausted,  in  less  than  a  month. 

Dissection  twenty-four  hours  after  death. — The  bones  in  the 
vicinity  of  the  ulcer  were  found  extensively  diseased,  and  partly 
removed  by  caries.  On  the  outside  of  the  cranium  there  were 
two  tubercles,  one  of  the  size  of  a  large  nut,  and  the  other  less 
by  one-half.  They  were  not  encysted,  and  were  entirely  com- 
posed of  tuberculous  matter  in  the  first  degree  of  softness.  One 
of  them  was  contained  in  a  hollow  on  the  surface  of  the  cranium. 
On  opening  the  thorax,  the  right  lung  seemed  completely  trans- 
formed into  one  tuberculous  mass ;  but  a  more  close  inspection 
showed  it  to  be  compressed  by  this  tuberculous  growth,  which 
was  contained  in,  and  completely  filled,  the  cavity  of  the  pleura. 
This  matter  was  of  the  consistence  of  cheese,  and  exhibited  no 
distinct  tubercles.  It  was  about  the  thickness  of  two  fingers  on 
the  anterior  and  posterior  parts  of  the  lung,  and  somewhat  thinner 
on  the  side.     A  portion  of  it,  of  the  size  of  a  walnut,  had  formed 

*  See  Zimmerman,  Traite  de  l'Experience. 

t  This  is  the  variety  of  soft  melanosis,  formerly  referred  .to  in  the  notes  to 
the  chapter  on  melanosis,  and  constituting  the  fourth  form  of  this  affection  no- 
ticed by  Laennec.  We  must  remark,  however,  that  the  black  striae  observed  in 
such  cases,  on  the  pleura  or  other  serous  membranes,  are  rather  the  result  of 
black  matter  impregnating  an  accidental  tissue,  than  of  the  matter  of  melanosis 
deposited  on  the  surface  of  the  membranes. — (M.  L.) 


564  ACCIDENTAL    PRODUCTIONS    IN    THE    PLEURA. 

a  passage  outwards  between  the  seventh  and  eighth  ribs,  (which 
were  carious,)  and  adhered  to  the  skin.  This  portion  was  as 
fluid  as  pus  in  its  center.  Another  portion  united  the  diaphragm 
to  the  base  of  the  lung,  and  also  to  the  ninth  and  tenth  ribs.  On 
detaching  this  layer  from  the  surface  of  the  pleura,  this,  in  place 
of  being  smooth,  was  found  uneven,  like  the  surface  of  the  cysts 
of  tubercles  ;  and  some  very  short  fibres,  like  a  fine  cellular  tissue, 
extended  from  it  into  the  morbid  production.  In  the  midst  of 
this  mass,  the  lung,  compressed  to  one-fifth  of  its  natural  size,  was 
found,  in  other  respects,  sound,  and  did  not  contain  the  slightest 
trace  of  tubercles.  There  was  a  small  quantity  of  serum  in  the 
left  pleura,  and  also  in  the  cavity  of  the  peritoneum,  and  the  liver 
was  not  quite  sound.  The  mesentery,  and  other  viscera,  were  in 
their  natural  condition. 

In  considering  the  means  of  discovering  a  case  of  this  kind 
during  life,  it  would  seem,  at  first,  that  the  stethoscope  could  only 
indicate  the  total  absence  of  respiration,  and  could  not,  therefore, 
enable  us  to  distinguish  such  an  affection  from  pleuritic  effusion, 
hydrothorax,  or  even  from  peripneumony  arrived  at  the  stage  of 
hepatization.  I  am  however  of  opinion,  that  a  careful  and  re- 
peated exploration  might  lead  us  nearer  to  the  knowledge  of  the 
truth,  if  it  did  not  quite  discover  it.  The  case  in  question  might 
be  distinguished  from  pleurisy  and  hydrothorax  by  the  circum- 
stance, that  in  these,  the  loss  of  the  respiratory  sound  is  sudden, 
whereas  in  the  case  of  the  tumor  it  must  begin  almost  insensibly, 
and  gradually  and  slowly  arrive  at  its  height.  The  want  of  aegoph- 
ony  in  the  latter  case  would  also  aid  the  diagnosis.  In  the  case 
of  pneumonia  we  have  the  crepitans  rhonchus  in  the  earlier  sta- 
ges ;  and  in  the  latter  stages  we  should  not  have  the  respiratory 
sound  at  the  roots  of  the  lungs,  which  would  be  found  in  the  case 
of  the  tumor,  even  after  this  had  reached  a  great  size.  It  must 
be  admitted,  however,  to  be  impossible  to  distinguish  the  cases  in 
question,  if  we  only  see  the  patient  in  the  advanced  stage  of  the 
affection.* 

*  I  found  in  the  thorax  of  a  man  aged  fifty,  at  the  hospital  Cochin,  an  enor- 
mous cancerous  mass,  whether  developed  within  or  without  the  pleura,  I  am 
ignorant.  This  individual  entered  the  hospital  in  a  very  reduced  slate.  The 
surface  of  the  right  side  of  the  chest  was  deformed  by  prominent,  irregular 
tumors,  hard  in  some  points,  and  fluctuating  in  others,  without  any  change  In 
the  color  of  the  skin.  All  this  side  of  the  chest  yielded  a  dull  sound  on  per 
cussion,  and  no  respiratory  murmur  could  he  heard  in  it.  The  patient  could 
give  no  clear  account  of  any  trouble  he  had  suffered  in  these  parts  in  the  course 
of  his  life  :  he  merely  stated  that  for  a  long  time  his  respiration  had  been  short, 
and  he  had  habitually  felt  pains  in  the  right  side  of  the  chest.  Otherwise  he 
had  all  the  symptoms  of  chronic  inflammation  of  the  alimentary  canal  :  he  soon 
died. 

On  opening  the  body  I  found  the  whole  of  the  right  side  of  the  chest  filled 
with  enormous  encephaloid  masses,  which  had  flattened  and  forced  aside  the 
lung  toward  the  vertebral  column,  as  it  happens  in  pleuritic  effusions      But  this 


ACCIDENTAL    PRODUCTIONS    IN    THE    PLEURA. 


iG5 


Sect.  III. — Of  Accidental  Productions  developed  on  the  adhe- 
rent or  outer  surface  of  the  pleura. 

Tumors  of  different  kinds  are  sometimes  found  developed 
between  the  pleura  of  the  ribs  and  thoracic  parietes.  I  have  met 
with,  in  this  situation,  only  the  medullary  tumor,  tubercles  of 
small  size,  and  cartilaginous  incrustations  ;  which  latter  bodies 
are  flattened  and  frequently  imperfectly  ossified.  These  are 
commonly*  considered  as  thickenings  of  the  pleura  ;  but  I  am  well 
assured  that  this  is  a  mistake  ;  as  is  also  the  supposed  thickening 
of  other  membranes,  such  as  those  of  the  spleen,  the  albuginea, 
the  inner  membrane  of  the  arteries,  &c*  I  have  met  with  carti- 
laginous incrustations  of  the  pleura,  as  large  as  the  hand,  and 
more  than  half  an  inch  thick  in  the  center,  which  seemed  to  have 
produced  hardly  any  symptoms  of  disease.  Haller  found,  in  this 
situation,  an  immense  cyst,  containing  a  serous  fluid,  and  com- 
pressing the  lung  to  the  size  of  the  hand.f  M.  Dupuytren 
found  two  enormous  cysts  of  the  same  kind,  in  the  body  of  a 
young  man,  who  died  of  suffocation,  after  having  long  labored 
under  a  progressively  increasing  dyspnoea.  Each  of  these  nearly 
filled  one  of  the  cavities  of  the  chest,  and  compressed  the  lungs 
into  a  small  compass  on  the  anterior  part  of  the  cavity.  "These 
cysts  were  eleven  inches  long  ;  their  walls  were  lined  with  a  great 
many  albuminous  layers,  having  on  them,  in  some  places,  very  fine 
granules,  and  in  others  small  vesicles."!  From  these  expres- 
sions, it  is  probable  that  these  cysts  may  have  contained  acepha- 
locyst-hydatids.  In  cases  of  this  kind,  I  think  the  attentive  con- 
sideration of  the  progress  of  the  disease  and  the  signs  furnished 
by  percussion  and  auscultation,  might  lead  to  a  sufficiently  cor- 
rect knowledge  of  the  affection  to  prompt  and  justify  the  opera- 
tion of  empyema.  And  this  would  probably  be  frequently  suc- 
cessful, particularly  if  .followed  by  injections  to  produce  the  in- 
flammation and  adhesion  of  the  cyst.  I  am  aware  that  this  latter 
practice  might  probably  be  sometimes  dangerous  ;  but  in  a  disease 
necessarily  fatal — melius  est  anceps  experiri  auxilium,  quam  nul- 
lum. 

was  not  all :  the  cancerous  tissue  in  extending  to  the  ribs,  had  in  a  great 
measure  destroyed  them,  and  it  was  this,  which,  issuing  from  the  cavity  where 
it  originated,  had  extended  to  the  exterior  and  formed  sub-cutaneous  tumors 
discernible  during  life.  In  a  short  time  they  would  have  softened,  and  vast 
cancerous  ulcers,  extending  from  the  pleura,  would  have  covered  the  thest. 
In  the  other  side  of  the  thorax  ever)'  thing  was  in  a  normal  state. 

\>  I  did  not  write  down  the  observations  at  the  time,  I  have  forgotten  what 
lesions  existed  in  the  digestive  or  other  organs. — Andrul. 

*  Diet.  desSc.  Med.  Art.  Cartil.  Accident. 

t   Opusc.  Pathol,  obs.  xiv. 

[  Essai  sot  I'Anat.  Path.  par.  J.  Cruvcilhier.     Paris,  1816. 


5bG  DIAPHRAGMATIC    HERNIA. 


Scet  IV. — Of  Diaphragmatic  Hernia. 

In  cases  of  wound,  some  part  of  the  abdominal  viscera  has 
passed  into  the  thorax.*  The  same  thing  has  followed  a  rupture 
of  the  diaphragm,  occasioned  by  a  fall,  by  great  exertion,f  or 
by  an  enormous  distension  of  the  stomach-!  The  same  derange- 
ment has  taken  place  from  original  malformation  of  the  dia- 
phragm ;<§>  and  even  by  the  natural  openings  in  that  muscle.  || 
Instances  have  occurred  in  which  the  stomach  and  the*  intestines 
have  been  found  in  the  left  cavity  of  the  chest. — A  case  of  this 
sort  would  be  easily  recognized  by  the  stethoscope,  from  the 
absence  of  respiration  in  the  chest,  and  the  presence  of  bor- 
borygmi  there.  In  a  case  of  this  kind,  discovered  shortly  after 
its  occurrence,  would  it  be  justifiable  to  make  an  incision  into 
the  abdomen  and  draw  back  the  intestines  ? — There  is  another 
species  of  hernia,  quite  as  rare  as  that  just  mentioned,  and  which 
might  also  be  discovered  by  means  of  the  stethoscope, — I  mean  a 
hernia  formed  by  the  lungs  through  the  intercostal  muscles. — 
Grateloup  has  published  a  case  of  this  kind,  which  was  produced 
by  violent  coughing.H  Boerhaave  records  a  similar  instance 
arising  from  the  exertions  during  labor  ;**  and  Sabatier  men- 
tions another  supervening  to  the  cicatrization  of  a  bayonet-wound 
between  the  fifth  and  sixth  ribs.ff  A  fourth  example  is  given  in 
the  third  volume  of  Richter's  Journal.  In  a  case  of  this  kind, 
the  stethoscope  would  at  once  detect  the  respiratory  sound  in  the 
tumor,  and  thus  discover  its  true  character. 

*  Ambroise  Pare,  liv.  ix.  ch.  xxx. — Leblanc.     Traite  d'Oper.  t.  ii.  p.  316. — 
Fabric,  de  Hild.  Cent.  ii.  obs.  xxxii. — Fanton,  Obs.  Med.  p.  167. 
t  Journ.  deDesault,  t.  iii. — Richter  on  Herniae. 
\  Haller,  Disput.  Chir.  torn.  iii. 

§  Hist,  de  l'Acad.  Roy  de  Sc.  1722.     Ibid.  1772.         ||  Richter,  Op.  Cit. 
IT  Journ.  de  Med.  t.  liii.  p.  416. 
**  De  Haen  Praelect.  in  Boerh.  Ins.  path.  t.  i.         ft  M6d.  Oper.  t.  ii.  p.  167. 


PART  THIRD. 

DISEASES  OF  THE  HEART  AND  ITS  APPENDAGES. 


BOOK  FIRST. 


OF    THE    EXPLORATION    OF    THE    ORGANS    OF    CIRCULATION. 

So  late  as  the  close  of  the  last  century,  affections  of  the  heart 
might  still  be  classed  among  those  diseases  which  are  the  most 
imperfectly  known.  They  were  considered  as  uncommon  ;  and 
notwithstanding  the  labors  of  Lancisi,  Morgagni,  and  Senac, 
the  common  run  of  practitioners  knew  of  no  other  cases  than  that 
of  polypus  of  the  heart  (an  imaginary  disease  in  their  acceptation 
of  the  term)  and  palpitation,  which  they  considered  as  a  nervous 
affection.  The  researches  of  the  authors  just  mentioned,  and 
those  of  Corvisart,  made  us  acquainted  with  many  organic  lesions 
of  the  heart,  but  threw  little  light  on  the  signs  of  these  ;*  inso- 

*  This  sentiment  seems  to  me  to  underrate  the  labors  of  Corvisart  and  others 
who  wrote  upon  the  diseases  of  the  heart  prior  to  the  discovery  of  auscultation; 
for  it  must,  in  justice,  be  acknowledged  that  there  are  well-established  rules 
laid  down  in  the  work  of  Corvisart,  by  which  many  of  the  diseases  of  the 
heart  can  be  distinguished  from  each  other. 

My  first  clinical  observations  were  made  at  a  period  when  auscultation  was 
not  practised,  and  yet  I  am  confident  that  in  a  majority  of  c*ses  I  could  readily 
distinguish  different  organic  affections  of  the  heart.  It  is  a  matter  of  surprise, 
however,  that  Corvisart  did  not  avail  himself  of  the  aid  of  percussion  in  the 
diagnosis  of  diseases  of  the  heart  and  pericardium;  for  it  must  be  admitted — 
thanks  to  the  art  of  auscultation  and  percussion — that  the  diseases  of  the  heart 
and  of  its  membranes,  are  much  better  understood,  and  certainly  much  more 
readily  distinguished  one  from  another  now  than  in  the  time  of  Corvisart.  A 
change  in  the  whole  aspect  of  the  science  in  this  respect,  was  wrought  by  the 
labors  of  Laennec;  and  since  the  publication  of  his  immortal  work,  the  re- 
searches of  others,  also  fruitful  in  their  results,  have  been  added  to  his.  Such 
are  the  works  of  M.  Piorry  on  percussion  of  the  heart;  of  Louis  on  pericarditis; 
of  Corrigan  and  others  upon  the  incompetency  or  deficiency  of  the  valves  ;  of 
Rouanet,  Mare  d'Espine,  Hope,  Magendie,  &c.  upon  the  cause  of  the  sounds 
of  the  heart ;  of  Bouillaud  upon  endocarditis,  also  of  this  last  named  professor 
upon  the  sounds  of  the  arteries,  and  a  multitude  of  other  points  in  the  pathology 
of  the  heart  and  pericardium,  which  have  been  presented  in  strong  and  clear 
light.  But,  notwithstanding  the  numerous  researches  which  have  been  made, 
the  history  of  diseases  of  the  heart  is  yet  far  from  being  completed.  It  still 
presents  doubts  to  be  cleared  up,  deficiencies  to  be  supplied,  and  the  period  has 


568  EXPLORATION    OF    THE    HEART. 

much  that,  in  the  state  in  which  the  science  was  left  by  them,  it 
was,  perhaps,  impossible  to  distinguish,  with  any  certainty,  one 
disease  from  another. 

The  positive  signs  of  the  organic  diseases  of  the  heart  are 
derived  partly  from  percussion,  but  chiefly  from  auscultation  ; 
and  by  means  of  them  also  many  of  the  common  symptoms  pro- 
duced by  disorder  of  the  functions,  and  in  themselves  extremely 
vague,  acquire  occasionally  a  much  greater  degree  of  certainty. 
The  application  of  the  hand,  the  only  method  in  use  before  the 
time  of  Avenbrugger,  furnishes  us,  in  most  cases,  with  no  result 
whatever,  and  frequently  deceives  us  in  respect  of  the  actual  force 
of  the  heart's  impulse  or  shock.  It  indicates  less  accurately  than 
the  pulse  at  the  wrist,  the  regularity  or  irregularity  of  its  con- 
tractions ;  it  is,  in  fact,  useful  in  one  particular  case  only,  that  of 
the  existence  of  the  peculiar  vibration  or  thrilling  (analogous  to 
the  purring  of  a  cat)  which  will  be  hereafter  described.  Even 
percussion  supplies  us  with  only  accessory  or  corroborative  signs, 
which  may  frequently  be  wanting.* 

not  yet  arrived  when  the  diagnosis  of  cardiac  diseases  may  be  regarded  so  cer- 
tain and  so  easy  as  that  of  pulmonary  affections.  But  in  regard  to  this,  as  to 
other  subjects,  we  are  confident  indeed  that  it  will  continue  to  advance,  as  it 
has  done,  from  the  time  of  Lancisi  to  Laennec,  and  from  Laennec  to  Bouillaud. 
Jlndral. 

*  It  is  true  in  some  instances,  that  percussion  affords  no  clue  to  the  alteration 
which  the  heart  may  have  undergone;  and  this  indeed  always  happens  when 
the  heart  is  enveloped,  as  it  were,  by  the  lung;  for  in  this  case,  the  precordial 
region  will  always  render  a  clear  sound,  while  the  heart  at  the  same  time,  may 
have  acquired^  dimensions  much  beyond  what  is  natural.  This  disposition  of 
the  lung  with  respect  to  the  heart,  is  found  most  frequently  in  individuals  who 
are  affected  with  pulmonary  emphysema.  But,  on  the  other  hand,  there  are 
cases  in  which  percussion  alone  furnishes  us  the  means  of  discriminating  be- 
tween palpitations  of  the  heart  which  are  purely  nervous  and  those  which 
depend  on  an  organic  affection.  To  be  sure,  we  cannot  always  say  what  por- 
tion of  the  heart  is  not  covered  by  the  lung;  but,  as  lias  been  remarked  by  M. 
Bouillaud,  it  being  generally  in  a  direct  ratio  with  the  size  of  the  heart,  the 
space  giving  rise  to  the  flat  sound  may,  to  a  certain  degree,  be  considered  as 
a  measure  of  the  augmentation  or  diminution  of  the  size  of  the  heart. 

In  the  natural  Sr  healthy  condition  of  tin;  hfeart,  when  it  is  covered  by  the 
lung  no  more,  nor  less  than  it  should  be,  the  dull  sound  which  it  produces 
should  extend  over  a  space  of  about  one  and  a  half  or  two  square  inches.  This 
space  becomes  considerably  lessened  in  case  the  lung,  whether  in  a  healthy  or 
emphysematous  state,  advances  before  the  heart  more  than  ordinary;  it  in- 
creases, on  the  contrary,  in  case  of  enlargement  of  the  heart  from  hypertrophy 
or  dilatation.  M.  Piorry,  who  has  made  so  many  excellent  observations  upon 
the  percussion  of  the  cardiac  region,  has  also  called  our  attention  particularly 
to  certain  cases,  in  which  this  region  renders  a  Hull  sound  over  a  much  greater 
extent  than  is  natural,  without  there  being  any  alteration  in  the  texture  of  the 
heart.  This  happens  in  those  eases  in  which  the  heart  becomes  distended  with 
a  greater  quantity  of  blood  than  it  usually  contains;  and  the  dull  sound,  which 
is  the  consequence,  presents  this  remarkable  circumstance  :  that  it  increases  and 
diminishes  in  proportion  to  the  degree  of  distention  of  the  heart,  so  that  by 
venesection  it  may  be  made  entirely  to  disappear. 

I  have  never  known  the  dullness,  produced  by  a  distention  of  the  heart,  to 
cover  more  than  six  square  inches ;  usually  it  is  observed  over  a  space  of  four 
square  inches.    Neither  have  I  ever  observed  the  dullness  arising  from  a  per- 


EXPLORATION    OF    THE    HEART. 


569 


In  reference  to  exploration,  we  must  notice  two  cardiac  regions, 
the  right  and  left ;  the  first  comprising  the  space  covered  by  the 
lower  third  of  the  sternum  ;  the  second,  that  which  corresponds 
to  the  cartilages  of  the  fourth,  fifth,  sixth,  and  seventh  sternal 
ribs. — The  right  cardiac  region  naturally  yields  a  very  clear 
sound.  Hypertrophy  of  the  ventricles,  the  dilatation  of  these  or 
of  the  auricles,  a  vast  accumulation  of  blood  in  all  the  cavities  of 
the  heart,  the  growth  of  much  fat  around  this  organ,  and  effusions 
into  the  pericardium,  may  render  the  sound  dull  or  dead.*  The 
same  causes  may  produce  the  same  effect  in  the  left  cardiac 
region :  but  in  this  case  the  sign  would  be  less  conclusive,  inas- 
much as  this  region  naturally  yields  but  little  sound  in  most  per- 
sons, and  hardly  any  in  fat  or  cedematous  subjects,  or  even  in 
such  as  are  very  muscular.  It  is  very  uncommon  for  the  sound 
to  be  wanting  in  either  region,  as  high  as  the  site  of  the  auricles : 
and  if  it  is  so,  it  indicates  an  enormous  dilatation,  such  as  exists 
only  in  the  case  of  contraction  of  the  mitral  orifice. 

The  alternate  contractions  of  the  auricles  and  ventricles  of  the 
heart  give  rise  to  sounds  very  distinct,  and  of  different  kinds,f  so 
as  to  enable  us  to  study  the  actions  of  that  organ  even  more  ex- 
actly than  by  the  dissection  of  living  bodies.  The  truth  of  this 
seemingly  paradoxical  assertion  rests  on  the  fact,  of  the  ear 
judging  much  more  correctly  of  the  intervals  of  sound,  than  the 
eye  of  the  intervals  of  motion  corresponding  to  these.  And  yet 
notwithstanding  this  advantage,  we  must  still  admit  with  Haller, 
that  the  analysis  of  the  movements  of  the  heart  is  difficult,  and 
requires  great  attention.  Certain  of  the  phenomena  of  the  sound 
organ,  are  especially  difficult  to  be  accurately  ascertained.     It  is 

manent  or  temporary  increase  in  the  size  of  the  heart  to  extend  to  the  sternum.  I 
have  always  observed  it  to  terminate  a  little  before  the  union  of  the  cartilages  of 
the  ribs  with  this  bone.  When,  however,  the  dull  sound  depends  upon  an  effusion 
into  the  pericardium,  it  is  much  greater  in  extent,  passing  beyond  the  cartilages 
of  the  ribs,  even  to  the  left  side  of  the  sternum.  This  fact  may  be  of  service 
when  we  would  distinguish  between  the  flat  sound  of  a  recently  formed  hydro- 
pericarditis,  and  that  which  may  arise  in  consequence  of  an  enlargement  of  the 
volume  of  the  heart. — Qndrol. 

*  Those  cases  in  which  the  heart  by  its  increased  size  produces  a  dullness 
in  the  lower  third  of  the  sternum,  are,  however,  extremely  rare.  In  regard  to 
this  point,  I  will  only  refer  to  what  has  already  been  stated  in  the  preceding 
note. — Andral. 

\  It  will  be.  seen  hereafter  that  Laennec's  opinion  of  the  two  sounds  of  the 
heart  being  produced  by  "  the  alternate  contractions  of  the  auricles  and  ventri- 
cles," is  far  from  being  confirmed  by  the  observations  of  his  successors  :  indeed 
there  can  be  little  doubt  now  in  the  mind  of  any  one,  that  our  author's  views  on 
this  point  are  incorrect.  Feeling  it  my  duty,  however,  to  render  the  text  faith- 
fully, and  yet  being  anxious  to  guard  against  mistake,  I  would  recommend  that, 
in  the  perusal  of  the  present  Part,  the  reader  should  endeavor  mentally  to  sub- 
stitute the  words  first  sound  for  our  author's  expression  contraction  of  the  ven- 
tricles, and  second  sound  for  contraction  of  the  auricles.  He  will  thus  retain  the 
facts — all  that  is  necessary  for  practical  purposes— whatever  explanation  of 
them  he  may  hereafter  be  led  to  adopt. —  Transl. 

72 


570  EXPLORATION  OF  THE  HEART. 

fortunate,  however,  that  the  results  which  lead  to  practical  con- 
sequences are  more  easily  obtained,  and  require  no  extraordinary 
attention,  and,  indeed,  the  most  important  of  all,  in  this  respect, 
are  such  as  can  hardly  escape  the  notice  of  the  least  attentive  and 
least  experienced  observer.  The  movements  of  the  heart  must 
be  studied  under  four  principal  heads ;  viz.  1  st,  the  extent  over 
which  they  can  be  heard  by  means  of  the  stethoscope ;  2nd,  the 
shock  or  impulse  communicated  by  them ;  3rd,  the  nature  and 
intensity  of  the  sound  ;  and  4th,  their  order  or  rythm.  Before 
commencing  this  analysis  of  the  heart's  actions  I  must  make  one 
observation,  on  which  I  shall  have  occasion  to  return  again  and 
again :  it  is  this — that  of  all  the  organs  in  the  body,  the  heart  is 
perhaps  that  which  is  the  least  frequently  in  the  most  favorable 
condition  for  exercising  its  functions  in  their  complete  integrity. 
Its  severest  diseases  consist  in  defects  of  proportion  ;  and  yet  a 
slight  disproportion  between  it  and  other  organs,  or  between  some 
of  its  own  constituent  parts,  is  compatible  with  a  state  of  health. 


CHAPTER  I. 

OF    THE    EXTENT    OF    THE    HEART'S    PULSATIONS. 

This  may  be  considered  in  two  points  of  view : — first,  the  sen- 
sation conveyed  by  the  instrument  when  applied  to  the  region  of 
the  heart;  and  secondly,  the  parts  of  the  chest  (beside  this 
region)  in  which  its  action  can  be  felt  or  heard.  In  the  natural 
condition  of  the  organ,  the  heart  examined  between  the  carti- 
lages of  the  fifth  and  sixth  ribs,  and  at  the  lower  end  of  the 
sternum,  communicates,  by  its  motions,  a  sensation  as  if  it  corres- 
ponded evidently  with  a  small  point  of  the  thoracic  parietes,  not 
larger  than  that  occupied  by  the  end  of  the  stethoscope.  Some- 
times, it  appears  as  if  it  were  placed  deep  in  the  mediastinal 
cavity,  leaving  a  vacant  space  between  it  and  the  sternum :  in 
this  case  its  movements,  even  when  pretty  energetic,  appear  to 
communicate  no  vibratory  impulse  to  the  neighboring  parts. 
In  other  cases,  again,  the  heart  seems  entirely  to  fill  the  cavity 
of  the  mediastinum,  and  to  extend  much  beyond  the  point  on 
which  the  instrument  rests ;  and  then  its  contractions,  even  when 
slow  and  noiseless,  seem  to  elevate,  to  a  considerable  extent,  the 
walls  of  the  chest  before  them,  or  to  displace  the  adjacent  viscera 
within.  This  difference  of  sensation  seems,  in  a  word,  to  convey 
the  impression  of  the  action  of  a  smaller  or  larger  heart ;  and, 
generally    speaking,  this  indication  is  sufficiently  correct,  when 


EXTENT    OF    PULSATIONS. 


571 


the  organ  is  examined  in  the  state  of  quietude  which  results 
simply  from  repose  of  body.  In  the  state  of  calm,  produced  by 
a  previous  bloodletting,  long-continued  quiescence,  fasting,  or 
exhaustion  from  disease,  the  extent  of  the  heart's  pulsations  will 
be  less  than  natural ;  and  on  the  other  hand,  in  a  state  of  agita- 
tion and  palpitation,  they  seem  more  extended  than  they  are  in 
reality. 

The  examination  of  the  different  points  of  the  chest  in  which 
we  can  perceive  the  heart's  pulsations  supplies  us  with  practical 
results  much  more  numerous  and  important.  In  a  healthy  per- 
son, moderately  stout,  and  whose  heart  is  well-proportioned,  the 
pulsations  of  this  organ  are  only  heard  in  the  cardiac  region, 
that  is,  in  the  space  comprised  between  the  cartilages  of  the 
fourth  and  seventh  ribs,  and  under  the  lower  end  of  the  sternum. 
The  motions  of  the  left  cavities  are  chiefly  perceptible  in  the 
former  place,  those  of  the  right  cavities  in  the  latter.  This  is 
so  much  the  case,  that,  in  disease  of  one  side  of  the  heart  only, 
the  pulsations  in  these  two  situations  give  quite  different  results. 
When  the  sternum  is  short,  the  pulsations  are  perceived  in  the 
epigastrium.  In  very  fat  subjects,  the  pulsations  of  whose  hearts 
are  quite  imperceptible  to  the  mere  touch,  the  space  in  which 
they  can  be  detected  by  the  stethoscope  is  sometimes  not  more 
than  an  inch  square.  In  thin  persons,  in  the  narrow-chested, 
and,  also,  in  children,  the  pulsations  are  more  extended :  being 
perceptible  over  the  third,  or  even  three-fourths,  of  the  inferior 
part  of  the  sternum,  and  sometimes-  even  over  the  whole  of  this 
bone ;  also  at  the  superior  part  of  the  left  side,  as  high  as  the 
clavicle,  and  sometimes,  though  feebly,  under  the  right  clavicle.* 
When  the  pulsations  are  confined  to  the  places  above  mentioned, 
in  subjects  of  the  kind  noticed,  and  when  they  are  much  weaker 
below  the  clavicles  than  in  the  region  of  the  heart,  we  may  con- 
clude that  this  organ  is  well  proportioned. 

When  the  pulsations  of  the  heart  become  more  extended, 
they  are  heard  successively  in  the  following  places: — 1.  the 
whole  left  side  of  the  chest,  from  the  axilla  to  the  stomach : 
2.  the  right  side  over  the  same  extent ;  3.  the  posterior  part 
of  the  left  side  of  the  chest ;  and,  4.  the  posterior  part  of  the 
right  side.  This  last  is  rare.  In  these  cases  the  intensity  of 
the  sound  is  progressively  less  in  the  succession  mentioned : 
for  instance,  it  is  less  under  the   right  clavicle  than  under  the 

*  It  does  not  appear  to  me  so  uncommon  for  the  pulsations  of  the  heart  to 
extend  along  the  sternum  and  the  costal  cartilages  of  the  right  side,  as  far  as 
under  the  clavicle,  as  Laennec  would  here  have  us  suppose.  Neither  is  it  abso- 
lutely necessary  that  the  subjects  should  be  children,  or  thin  or  narrow  chested. 
The  fact  is,  so  common  is  it  to  all  possible  conditions  of  health,  for  the  pulsations 
of  the  heart  to  be  heard  in  the  right  side  of  the  chest,  that  it  should  not  be  con- 
sidered as  indicating  any  pathological  condition. — Andral. 


572  EXPLORATION  OF  THE  HEART. 

left :  it  is  somewhat  less  on  the  lateral  parts  of  the  left  side,  than 
under  the  clavicle ;  it  is  still  less  perceptible  on  the  right  side 
laterally ;  and  much  attention  is  requisite  to  enable  us  to  hear 
the  pulsations  at  all  on  the  back,  particularly  the  right  side. 
This  succession  has  appeared  to  be  constant,  and  may  be  taken 
as  an  index  of  the  extent  of  pulsation.  For  instance,  if  this  be 
perceptible  on  the  right  side,  we  may  be  assured  that  it  will  be 
equally  so  over  the  whole  sternum,  under  both  clavicles,  and 
over  the  left  side ;  but  we  are  not  sure  that  it  will  be  so  on  the 
back.  But  if  it  be  perceptible  on  the  back  on  the  right  side, 
we  may  calculate  on  its  being  still  more  audible  in  every  other 
part  of  the  chest. 

Several  circumstances  unconnected  with  the  state  of  the  heart 
may  derange  the  order  above  mentioned,  and  augment  the  extent 
of  the  pulsations.  I  have  already  noticed  the  effect  of  emaciation 
and  narrowness  of  chest.  In  young  children,  and  in  persons  of 
all  ages,  whose  bones  are  small  and  whose  chest  is  narrow  and 
little  covered  with  flesh,  the  pulsations  are  heard  over  the  whole 
thorax.*  A  hepatized  lung,  or  one  strongly  compressed  by  an 
effusion  in  the  chest,  transmits  the  pulsations  better  than  a 
healthy  lung  permeable  to  air.  This  result  accords  with  the 
general  principle  of  solid  bodies  being  the  best  conductors  of 
sound.  But  it  has  also  appeared  to  me  that  the  anfractuous 
excavations  in  the  lungs,  produced  by  the  softening  of  tubercles, 
have  constantly  the  same  effect ;  a  circumstance  not  so  easily  ex- 
plained, unless  we  suppose  that,  in  this  case,  the  sound  is  trans- 
mitted, not  through  the  cavities,  but  along  their  indurated  and 
condensed  boundaries.  It  is  thus,  that,  in  the  case  of  tuberculous 
excavations  in  the  summit  of  the  right  lung,  we  shall  hear  the 
pulsation  of  the  heart  better  under  the  right  clavicle  and  axilla, 
than  on  the  left  side,  and  sometimes  even  better  than  in  the  very 
region  of  the  heart.t  When  the  sound  of  respiration  or  the 
rhonchus  is  very  great,  the  pulsation  of  the  heart  is  sometimes 
perceptible  on  the  sides  and  even  on  the  back,  although  it  is 
inaudible  under  the  clavicles,  being  there  completely  masked  by 
the  other  sounds. 

It  may  be  imagined  that  in  our  explorations  we  may  confound 
the  pulsation  of  the  aorta  and  subclavian  arteries  with  that  of 
the  heart.  This  mistake,  however,  is  not  possible,  as  will  be 
shown  more  particularly  afterwards.  It  is  sufficient  to  know 
that  under  all  circumstances  the  heart  gives  two  distinct  beats 

*  In  infancy  the  heart  is  proportionally  larger  than  in  adults;  and  its  cavities 
larger  in  relation  to  the  thickness  of  their  walls. — Author. 

t  It  has  appeared  to  me  generally  true,  that  tuberculous  excavations  and  pneu- 
mothorax transmit  the  sound  of  the  heart  rather  than  its  impulse  ;  while  hepa- 
tization of  the  lung  and  compression  from  effusion,  occasion  results  the  reverse 
of  these.— Author. 


EXTENT    OF    PULSATIONS. 


573 


for  every  stroke  of  the  pulse.  Besides,  I  can  state  that  out  of 
the  thousands  of  persons  whom  I  have  examined,  in  a  state  of 
health  or  disease,  I  have  only  met  with  three  or  four  instances 
in  which  the  subclavian  arteries  could  be  heard  (except  in  the 
case  of  the  bellows-sound.)  And  it  is  only  in  the  case  of  aneu- 
rism, of  the  bellows-sound,  or  of  increased  impulse,  that  we  can 
perceive  the  pulsation  of  the  aorta  and  arteria  inominata :  and 
we  recognize  them  also  from  their  simple  pulsation. 

When  the  pulsation  of  the  heart  is  heard  over  a  greater  extent 
than  what  is  above  stated  to  be  the  range  of  a  well  proportioned 
organ,  the  individual  rarely  enjoys  good  health.  In  examining 
him  attentively  we  shall  discover  indications  of  that  cachexy 
peculiar  to  some  diseases  of  the  heart ;  and  we  shall  find  that  if 
he  has  not  formal  dyspnoea,  his  respiration  is,  at  least,  shorter 
than  usual,  and  he  is  put  more  easily  out  of  breath,  and  is  more 
subject  to  palpitation.  This  state,  however,  which  is  that  of 
many  asthmatics,  may  remain  stationary  many  years,  and  does 
not  always  prevent  the  attainment  of  an  advanced  age.  With 
regard  to  the  relation  between  the  state  of  the  heart  and  the  ex- 
tent of  its  pulsations,  I  think  it  may  be  taken  as  a  general  fact, 
that  the  extent  of  pulsation  is  in  the  direct  ratio  of  the  thinness 
and  weakness  of  the  heart,  and  consequently,  inversely  as  its 
thickness  and  strength.  The  size  of  the  organ  must  also  be  con- 
sidered as  favoring  extent  of  pulsation,  except  in  the  case  where 
the  augmentation  of  size  depends  entirely  on  thickening  of  the 
walls  of  the  ventricles. 

The  above  results  are  derived  from  the  whole  of  the  dissections 
made  by  me  during  the  last  ten  years ;  as  I  have  not  met  with  a 
single  fact  calculated  to  throw  any  doubt  on  their  accuracy. 
Thus,  if  the  pulsations  extend  over  almost  all  the  places  above 
mentioned,  we  may  presume  that  the  heart  is  increased  beyond 
the  natural  size,  and  that  this  increase  is  owing  to  the  dilatation 
of  one  or  both  ventricles.  This  presumption  will  be  strengthened, 
if  the  pulsations  are  as  great  (or  greater)  under  the  clavicles  or 
in  the  axilla,  as  in  the  region  of  the  heart.  The  consideration 
of  other  signs  to  be  hereafter  mentioned,  will  render  our  diag- 
nosis more  certain,  and  point  out  more  precisely  the  site,  the 
extent,  and  the  nature  of  the  organic  disease.  I  am  far  from 
wishing  to  assert  that  we  ought  to  form  our  judgment  from  one 
sign.  I  wish  to  give  to  each  its  true  value  ;  and  think  it  hardly 
necessary  to  state,  that  their  value  is  greatly  enhanced  when  they 
co-exist.  Besides,  when  we  come  to  treat  of  the  peculiar  signs 
of  each  particular  disease,  we  shall  be  able  to  correct  what  may 
appear  in  this  analysis  to  be  stated  in  a  manner  too  absolute. 

If  the  pulsations  are  perceived  neither  in  the  back  nor  right 
side,  but  only  in  the  other  points  mentioned,  and  if  their  inten- 


574  EXPLORATION  OF  THE  HEART. 

sity  is  nearly  equal  in  all  these,  we  may  conclude  that  the  ven- 
tricles are  moderately  dilated,  and  that  the  walls  of  the  heart 
are  naturally  thin.  On  the  contrary,  when  the  pulsations  are  felt 
very  strong  in  the  region  of  the  heart,  and  are  not  perceived  at 
all  or  only  very  slightly  under  the  clavicle,  we  may  be  assured 
(if  the  patient  has  other  general  symptoms  of  diseased  heart)  that 
the  disease  is  hypertrophy  of  the  ventricles.  The  special  signs 
will  point  out  which  ventricle  is  affected.  If  the  patient  has 
never  experienced  any  marked  disorder  of  the  circulatory  organs, 
we  may  be  certain  that  the  walls  of  the  left  ventricle  are  both 
firm  and  thick,  though  still  not  sufficiently  so  to  constitute  dis- 
ease. Generally  speaking  then,  it  may  be  taken  for  granted  that 
a  great  extent  of  sound  is  a  mark  of  thin  parietes  of  the  heart, 
more  particularly  of  the  ventricles  ;  and  that  a  confined  range 
of  sound  coincides  with  an  increased  thickness  of  these.  Some 
accidental  causes  may  augment  for  a  time  the  extent  of  the 
heart's  pulsation,  such  as  nervous  agitation,  fever,  palpitation, 
haemoptysis,  and,  in  general,  whatever  increases  the  frequency 
of  the  pulse. 

This  mode  of  appreciating  the  extent  of  the  heart's  pulsations 
by  the  number  and  site  of  the  places  in  which  they  can  be  per- 
ceived appears  to  be  of  great  certainty  and  practical  utility  : 
the  gradation  just  mentioned  is  constant,  with  the  exceptions  for- 
merly noticed.  Once  or  twice  only  have  I  had  occasion  to  hear 
the  pulsations  more  distinctly  on  the  left  back  than  on  the  right 
side  anteriorly,  in  cases  wherein  I  could  not  attribute  the  anomaly 
to  the  probable  presence  of  pulmonary  excavations;  and  the 
rareness  of  this  fact  ought,  in  my  opinion,  to  cause  it  to  be  re- 
garded as  an  exception  occasioned  by  some  analogous  circum- 
stances,— perhaps  by  a  variety  in  the  capacity  or  position  of  the 
great  bronchial  trunks.  In  certain  cases,  in  which  the  sound  of 
the  auricles  is  little  perceptible  in  the  cardiac  region,  it  is  usually 
heard  better  a  little  higher  up,  or  even  under  the  clavicles  ;  and 
sometimes  even  on  the  back. 

In  examining  the  extent  of  pulsation,  the  stethoscope  has  a 
decided  advantage  over  the  naked  ear,  which  tannot  be  applied 
to  the  axilla,  nor  beneath  the  clavicles,  nor  between  the  scapulae 
in  very  lean  subjects. 


IMPULSE    OR    SHOCK. 


575 


CHAPTER  II. 

OF    THE    SHOCK    OR    IMPULSE    COMMUNICATED    TO    THE    EAR   BY 
THE    ACTION    OF    THE    HEART. 

I  understand  by  shock  or  impulse,  the  sensation  of  upward 
pressure  or  percussion  communicated  to  the  ear  of  the  auscultator 
by  the  action  of  the  heart.  This  pressure  is  perceived  by  means 
of  the  stethoscope  in  the  cases  where  the  hand  applied  to  the  re- 
gion of  the  heart  communicates  no  sensation ;  and,  on  the  con- 
trary, the  impulse  appears  very  great  to  the  hand,  in  lean  sub- 
jects, and  particularly  during  flurry,  when  the  stethoscope  proves 
the  real  impulse  to  be  small. 

We  must  be  careful  not  to  confound  with  the  impulse  of  the 
heart,  the  rise  of  the  thoracic  parietes  during  inspiration.  This 
caution  is  more  particularly  necessary  when  the  respiration  is 
very  short  and  frequent,  and  is  performed  with  great  labor,  as 
in  the  agony  of  most  diseases,  and  in  paroxysms  of  dyspnoea. 
The  degree  of  impulse  communicated  by  the  stethoscope  to  the 
ear,  is,  in  general,  inversely  as  the  extent  of  the  pulsation  of  the 
heart,  and  directly  as  the  thickness  of  the  walls  of  the  ventricles. 
In  a  person  whose  organs  of  circulation  are  well-proportioned, 
this  impulse  is  very  little  perceptible,  often  quite  imperceptible, 
especially  if  the  individual  is  rather  fat.  Quick  walking  or 
running,  or  the  act  of  ascending  a  height,  nervous  flurry,  palpi- 
tation, and  fever,  commonly  augment  the  impulse  in  subjects  the 
walls  of  whose  hearts  are  rather  thick,  and  still  more  when  they 
are  so  much  so  as  to  constitute  actual  hypertrophy.  In  this  case, 
the  impulse  is  usually  so  great  as  very  sensibly  to  elevate  the 
head  of  the  observer,  and  sometimes  to  give  a  disagreeable  shock 
to  the  ear.  The  more  intense  the  hypertrophy,  the  longer  time 
the  impulse  is  perceptible.  When  the  disease  exists  in  a  high 
degree,  we  feel  as  if  the  heart,  in  dilating,  first  comes  in  contact 
with  the  walls  of  the  chest  in  one  point  only,  and  then  with  its 
whole  surface,  and  that  it  contracts  and  falls  back  all  at  once. 
When  the  heart  is  thin,  the  same  causes  produce  a  different  re- 
sult, as  we  shall  see  hereafter. 

The  impulse  of  the  heart  is  only  felt  during  the  systole  of  the 
ventricles  ;  or  if,  in  some  rare  cases,  an  analogous  phenomenon 
accompanies  the  contraction  of  the  auricles,  this  is  easily  dis- 
tinguished from  the  former.  In  fact,  when  the  systole  of  the 
auricles  is  attended  by  any  sensible  action,  this  is*  perceived  to 
have  its  seat  much  deeper ;  and  the  heart  even  seems  to  be  re- 
ceding from  the  ear.     Most  commonly  the  motion  consists  merely 


576  EXPLORATION  OF  THE  HEART. 

of  a  sort  of  trembling,  felt  deep  within  the  mediastinum.  In  any 
case,  it  is  very  little  marked  as  compared  with  the  sensation  pro- 
duced by  the  contraction  of  the  ventricles,  when  these  are  of  a 
arood  degree  of  thickness.  When  the  walls  of  the  heart  are  thin- 
ner  than  usual,  no  impulse  is  communicated,  even  when  the  pul- 
sation is  the  greatest :  and,  in  this  case,  the  alternate  contraction 
of  its  cavities  is  only  distinguished  by  the  sound  these  produce. 
A  strong  impulse,  therefore,  must  be  regarded  as  the  chief  sign 
of  hypertrophy  ;  and  the  absence  of  all  impulse,  (conjointly  with 
other  general  and  local  signs,)  as  characteristic  of  dilatation  of 
the  heart.  This  result  appears  to  me  quite  constant ;  at  least  I 
have  not  hitherto  met  with  one  exception  to  it ;  and  it  is  now 
supported  by  a  very  considerable  number  of  facts.  Since  the 
beginning  of  my  researches  on  auscultation,  I  have  made  a  point 
of  ascertaining  the  character  of  the  heart's  pulsations  in  all  my 
hospital  patients,  and  in  no  case  has  examination  after  death  in- 
validated the  rule  above  laid  down. 

The  impulse  of  the  heart's  action  is  usually  perceptible  only 
over  the  region  of  the  heart,  or,  at  most,  over  the  inferior  half  of 
the  sternum.  When  very  great,  it  extends  to  the  epigastrium  in 
cases  where  the  sternum  is  short.  Tn  simple  hypertrophy  it  is 
usually  perceived  in  no  other  part,  even  when  the  pulsations  are 
heard  in  other  points  of  the  chest :  but  when  this  is  conjoined 
with  a  certain  degree  of  dilatation,  it  is  sometimes  distinctly  per- 
ceived under  the  clavicles,  and  in  the  left  side  of  the  chest ;  and 
sometimes  even  on  the  back,  in  a  slight  degree. 

There  is  one  case  in  which  we  are  able  in  some  degree  to  dis- 
tinguish the  shock  communicated  to  the  walls  of  the  chest,  from 
that  conveyed  to  the  ear.  This  is  the  complex  case  of  hyper- 
trophy and  dilatation  of  the  ventricles,  but  with  the  latter  affec- 
tion more  marked  than  the  former.  In  cases  of  this  kind  the  im- 
pulse is  usually  not  great,  except  during  the  existence  of  palpita- 
tion ;  and  it  has  a  very  different  character  from  that  produced 
by  simple  hypertrophy  :  the  beat  of  the  heart  is  hard,  with  a 
sound  like  that  produced  by  the  blow  of  a  mallet ;  but  the  blow 
seems  confined  to  a  small  space  ;  it  is  expended  on  the  walls  of 
the  chest,  and  does  not  communicate  to  the  ear  an  elevation  or 
upward  pressure  proportioned  to  its  force  ;  it  differs  from  the  im- 
pulse occasioned  by  a  strong  hypertrophy  in  this,  that,  in  the  lat- 
ter case,  the  distended  ventricles  appear  to  come  in  contact,  in 
their  whole  length,  with  the  walls  of  the  chest,  which  yield  before 
their  pressure  ;  whilst  in  the  other  case,  the  mere  point  of  the 
heart  seems  to  strike  the  thoracic  parietes,  with  a  sharp  definite 
blow,  which  produces  in  these  rather  a  vibration,  than  an  actual 


IMPULSE    OK    SHOCK. 


577 


elevation.     The  same  result  is  observed,  but  in  a  less  degree  in 
purely  nervous  palpitations.* 

Bloodletting,  diarrhoea,  severe  and  long  continued  abstinence, 
and,  in  general,  everything  capable  of  weakening  the  system,  di- 
minish, in  a  marked  degree,  the  impulse  of  the  heart.  For  this 
reason,  when  we  see  a  patient  for  the  first  time,  in  the  course  of  a 
disease  which  has  already  produced  a  great  diminution  of  strength, 

*  The  force  of  the  heart's  pulsations  is  indicated  by  the  shock  which  they 
impart  to  the  walls  of  the  thorax  during  each  systole  of  the  ventricles;  though, 
most  commonly,  except  in  cases  where  some  obstacle  is  opposed  to  the  free 
passage  of  the  blood  through  the  aortic  valves,  the  character  of  the  pulse  indicates 
the  different  degrees  of  energy  with  which  the  left  ventricle  contracts.  But 
with  our  present  means  of  investigation,  we  can  only  estimate  in  a  very  unsatis- 
factory manner  the  great  variety  of  conditions  which  the  pulse  offers  in  regard 
to  its  force ;  and  it  would  be  a  matter  of  no  little  importance,  could  some  means 
be  devised  by  which  we  could  estimate  its  force  with  as  much  exactness,  as,  by 
the  second  hand  of  a  watch,  we  can  note  its  frequency.  Dr.  Herison  has  pro- 
posed to  physicians  to  make  use  of  an  instrument  for  this  purpose,  which  he 
has  called  sphygometre,  or  pulse  glass.  This  instrument  consists  of  a  graduated 
glass  tube,  which  terminates  in  a  kind  of  reservoir  filled  with  mercury  and 
covered  with  gold-beater's  skin.  The  slightest  compression  made  upon  this 
causes  the  mercury  to  rise  in  the  tube  to  an  height  corresponding  to  the  force 
of  the  compression.  This  instrument  being  applied  to  the  radial  artery,  the 
column  of  mercury  will  be  seen  to  rise  in  the  tube,  with  a  frequency  and  regu- 
larity corresponding  exactly  with  the  force  and  order  of  succession  of  the 
arterial  pulsations.  It  certainly  would  be  a  very  happy  circumstance  if  we 
could  have  it  in  our  power  to  avail  ourselves  of  all  the  benefits  of  the  simple 
touch  which  is  frequently  so  uncertain  and  so  variable  to  different  obs.ervers, 
by  an  instrument  which  calculates  with  so  great  precision  the  different  degrees 
of  force  and  impulse  of  the  arteries,  and  consequently  also  of  the  heart. 

The  sphygometre  which  Dr.  H.  has  constructed  must,  however,  to  be  of  real 
service,  be  brought  to  a  much  higher  degree  of  perfection  than  it  now  possesses. 

In  a  memoir  read  to  the  Royal  Academy  of  Medicine,  Dr.  H.  not  only  an- 
nounces that  by  the  aid  of  this  instrument  he  can  determine  with  the  most  rigid 
exactness  the  force  of  the  pulse  and  the  cases  in  which  bloodletting  can  be 
practised  with  the  greatest  advantage,  but  he  also  assures  us  that  by  it  he  can 
distinguish  organic  affections  of  the  heart,  and  even  can  determine  their  nature. 
And  he  does  not  hesitate  to  add,  that  there  are  cases  in  which  his  new  instru- 
ment furnishes  even  more  positive  indications  of  the  condition  of  the  heart, 
than  the  stethoscope  itself. 

The  signs,  as  indicated  by  the  sphygometre,  which  Dr.  H.  has  laid  down  in 
his  memoir,  and  which  he  says  he  has  always  observed  in  individuals  affected 
with  hypertrophy  of  the  heart  or  with  a  contraction  of  its  orifices,  are  the  fol- 
lowing:— 

I.  Hypertrophy  without  contraction. 

(a)  With  thickening  of  the  walls  and  the  diminution  of  the  capacity  of  the 
left  ventricle — impulse  brisk,  arterial  resistance  very  strong. 

(b)  With   thickening   of  the  walls  and   increase  in   the  capacity  of  the  left 
ventricle — impulse  very  strong,  unequal,  resisting. 

II.  Hypertrophy  with  contraction  of  the  right  auriculo-ventricular ,  or  ventricu- 
lo-pulmonary  orifice;  pulse  irregular,  unequal,  intermittent.  The  column  of 
mercury  hesitates,  as  it  were,  and  after  rising,  does  not  uniformly  regain  its  point 
of  departure. 

III.  Hypertrophy  with  tontraction  of  the  left  auriculo-ventricular  orifice,  or 
rentriculo-aortic  orifice;  pulse  irregular,  intermittent,  unequal,  compressible. 
The  eclumn  of  mercury  sinks  below  its  proper  level  by  a  kind  of  suction,  which 
continues  one,  two  or  three  seconds,  according  to  the  importance  of  the  obstacle 
which  presents,  and  at  intervals  differing  in  length,  according  to  the  nature  of 
the  alterations  of  the  valves. — Andral. 

73 


578  EXPLORATION  OF  THE  HEART. 

it  may  happen  that  the  stethoscope  shall  not  discover  hypertrophy 
of  the  ventricles,  if  existing  in  only  a  middling  degree.*  The 
heart's  impulse,  in  like  manner,  frequently  ceases  altogether,  even 
in  cases  where  the  hypertrophy  is  considerable,  upon  the  super- 
vention of  very  intense  dyspnoea,  in  cases  of  pneumonia,  pleurisy, 
oedema  of  the  lungs,  asthma,  or  in  the  congestions  immediately 
preceding  death.f  The  clear  sound  which,  as  we  shall  see,  ac- 
companies dilatation  of  the  heart,  in  like  manner  diminishes  or 
entirely  disappears  under  similar  circumstances.  We  must  not, 
therefore,  deduce  any  conclusions  from  explorations  made  at  such 
times.J 

*  It  is  true,  debility  lessens  the  impulse  of  the  heart,  and  in  this  way  renders  a 
slight  hypertrophy  of  this  organ  quite  obscure  :  but  it  is  a  circumstance  worthy 
of  notice,  that  in  certain  states  accompanying  excessive  debility,  the  pulsations 
of  the  heart,  so  far  from  being  weakened,  are,  on  the  contrary,  so  much  increased 
that  they  cannot  fail  to  apprize  us  of  an  existing  hypertrophy.  It  seems  then 
that  in  proportion  as  the  blood  deteriorates  and  general  debility  increases,  just  in 
that  proportion  does  the  influence  of  the  nervous  system  predominate,  in  conse- 
quence «of  which  the  contractions  of  the  heart  become  more  intense. 

The  increase  of  the  impulse  observed  in  these  cases  is  then  the  result  of  a  disor- 
der supervening  upon  the  innervation  of  the  heart,  and  this  again  is  the  result  of 
the  impoverished  state  of  the  blood ;  a  remarkable  example  of  the  increased 
activity  of  an  organ  co-existing  with  a  corresponding  decrease  in  the  power  of 
that  organ. 

Hence  it  is,  that  we  se*e  the  most  alarming  convulsions  supervene  upon  an  ex- 
tensive haemorrhage,  and  a  high  morbid  sensibility  and  the  various  forms  of 
delirium  follow  any  considerable  loss  of  blood. 

How'dreadfully  fataj  would  be  the  mistake  of  that  physician,  who,  under  cir- 
cumstances like  these,  with  an  eye  only  upon  this  kind  of  partial  hypersthenia, 
regardless  of  the  state  of  more  general  asthenia,  should  have  recourse  to  deple- 
tion for  relief.  He  would  see  the  disease,  under  his  own  hands,  increase  with  a 
frightful  rapidity.  It  should  never  be  forgotten,  on  the  contrary,  that  by  raising 
the  general  tone  of  the  system,  these  accidents  disappear.  Hence  it  is  that  the 
various  preparations  of  iron  are  so  effectual  in  relieving  palpitations  of  the 
heart  which  so  often  accompany  chlorosis,  and  which  from  their  long  continu- 
ance and  severity  are  often  mistaken  for  palpitations  arising  from  hypertrophy 
of  the  heart. — Andral. 

t  There  are  remarkable  cases  besides  the  one  here  referred  to  by  Laennec,  in 
which  the  existence  of  an  hypertrophy  of  the  heart  is  not  indicated  by  any  in- 
crease in  the  impulse.  This  I  have  had  occasion  to  observe  in  patients  in 
whom  the  heart  had  acquired  an  enormous  size,  in  consequence  of  a  dilatation 
of  its  cavities  and  thickening  of  their  walls.  It  frequently  happens,  also,  in 
these  cases,  that  the  pulsations  of  the  heart  become  almost  imperceptible',  much 
more  obscure  and  confused  than  in  the  natural  state.  Thus,  hypertrophy  of  the 
heart  is  not  invariably  accompanied  with  an  increased  energy  of  its  contractions. 
Aniral. 

\  It  is  during  the  systole  of  the  ventricles  that  the  heart  strikes  against  the 
walls  of  the  chest  and  produces  the  sensation  of  a  shock.  It  might  seem  a  priori, 
that  the  opposite  of  this  would  take  place,  inasmuch  as  the  fleshy  tissue  which 
constitutes  the  walls  of  the  ventricles  recoils  upon  itself  and  consequently  must 
be  drawn  from  the  thoracic  walls. 

The  attempt,  for  a  long  time,  has  been  made  to  reconcile  this  apparent  con- 
tradiction between  theory  and  observation,  by  proving  that  at  the  moment  the 
contraction  of  the  ventricles  takes  place,  they  are  thrown  forward  by  the  opera- 
tion of  three  different  causes— to  wit:  by  the  dilatation  of  the  auricles,  by  that 
of  the  aorta  and  pulmonary  artery,  and  finally,  by  the  straightening  which  the 
arch  of  the  aorta  must  necessarily  undergo  at  each  contraction  of  the  left  ventri- 
cle. 


OF    THE    SOUND.  ^  ' J 


CHAPTER  III. 

OF    THE    SOUND    PRODUCED    BY    THE    MOTIONS    OF    THE    HEART. 

The  alternate  contraction  of  the  different  parts  of  the  heart  pro- 
duces a  peculiar  sound,  of  which  the  individual  is  himself  sensible 

Such  an  explanation  as  this  does  not  appear  to  me  admissible,  and  I  believe 
with  M.  Bouillaud,  that  the  efficient  cause  of  this  impulse  is  to  be  found  in  the 
mode  of  the  contraction  of  the  ventricles,  or  rather  in  the  disposition  of  the 
muscular  fibres  which  compose  their  walls.  These  fibres  so  far  as  at  present  is 
known,  lie  coiled  upon  themselves,  having  their  fixed  point  in  the  tendinous 
circles  which  separate  the  ventricles  from  the  auricles.  These  shortening  them- 
selves during  contraction,  the  apex  of  the  heart  undergoes  a  sort  of  erectile 
movement,  by  which  it  is  thrown  against  the  walls  of  the  chest.  The  dilatation 
of  the  auricles  and  arteries  contributes  so  little  to  the  movements  of  the  ventricles, 
during  their  systole,  that  the  apex  of  the  heart  may  be  seen  to*  rise  for  some  mo- 
ments after  the  organ  has  been  separated  from  the  body  of  the  living  animal. 

The  shock  produced  by  the  action  of  the  heart  against  the  thoracic  walls, 
depends  for  the  most  part,  in  the  natural  state  at  least,  upon  the  contraction  of 
the  left  ventricle  ;  the  right  has  little  to  do  with  it. 

Dr.  Filhos,  who  has  made  some  valuable  researches  on  the  physiology  and 
pathology  of  the  heart,  has  also  attempted  to  prove  that  the  right  ventricle  has 
no'influence  in  the  production  of  this  phenomenon  :  and  in  order  to  establish 
his  opinion,  he  observes  that  if  the  left  ventricle  strikes  against  the  walls  of  the 
chest  during  its  contraction,  it  is  owing  to  the  spiral  disposition  of  the  muscular 
fibres  which  arc  situated  about  the  apex  of  the  heart :  these  coiling  up,  ihe  apex 
is  suddenly  elevated  and  thrown  a  little  forward.  The  muscular  fibres  of  the 
right  ventricle,  on  the  contrary,  not  having  this  spiral  arrangement,  can  produce 
no  such  movement. 

The  shock  which  the  heart  produces  against  the  thoracic  walls,  takes  place, 
in  a  healthy  state,  only  during  the  systole  of  the  ventricles;  but  in  some  patho- 
.logical  conditions  it  happens  otherwise.  I  have  seen  a  case,  for  instance,  where, 
immediately  succeeding  the  first,  shock,  which  corresponded  with  the  contraction 
of  the  ventricles,  two  others  were  distinctly  perceived  corresponding  with  the 
dilatation  of  the  ventricles.  M.  Bouillaud  has  cited  a  case  very  similar  to  the 
one  of  which  I  have  just  spoken.  He  has  *>een  a  female  in  whom,  by  applying 
his  handover  the  region  of  the  heart,  he  distinguished  three  different  movements. 
"The  first  and  much  the  strongest,  corresponded"  says  this  learned  professor 
"  with  the  pulse  and  the  first  bruit,  consequently  with  the  systole  :— the  two 
others  succeeded  immediately  to  the  first  and  were  synchronous  with  the  dias- 
tole. By  fixing  the  eye  upon  the  cardiac  region,  three  pulsations  could  be  dis- 
tinctly seen,  the  two  last  not  so  distinctly  as  the  first.  In  short,  by  attentively 
observing  the  head  of  the  individual,  while  examining  the  pulsations  of  the 
heart  with  the  ear  applied  closely  to  the  walls  of  the  chest,  it  could  be  seen  to 
be  agitated  by  three  distinct  movements    on  every  pulsation  of  the  radial  artery. 

The  auricles,  sometimes,  also  become  hypertrophied  and  like  the  ventricles, 
produce  a  very  distinct  shock.  M.  Bouillaud  has  likewise  cited  a  very  remark- 
able instance  of  this  kind.  He  speaks  in  his  work  on  the  diseases  of  the  heart, 
of  a  female  who  was  affected  with  an  enormous  hypertrophy  of  the  heart,  with 
induration  of  the  mitral  valves  in  whom  a  distinct  impulsive  movement  was 
communicated  to  the  left  infra-clavian  region,  between  the  second  and  third 
outer  costal  spaces.     The  ventricular  impulse  was  perceived  two  inches  below. 

This  same  author,  whom  I  shall  frequently  refer  to  in  the  course  of  these 
notes,  thinks  that  the  very  remarkable  rotundity  which  the  precordial  region 
frequently  presents  in  cases  of  considerable  hypertrophy  of  the  heart,  may  be 
owing  to  the  increased  energy  of  its  impulse.  This  rotundity  which  was  first 
observed  by  M.  Bouillaud,  unquestionably   exists  in  a  great  number  of  cases, 


580  EXPLORATION  OF  THE  HEART. 

during  palpitation  and  in  nervous  or  febrile  excitement :  more 
especially  if  lying  on  the  side,  with  the  ear  compressed  against  a 
cushion.  This  sound,  however,  is  perceived  by  the  patient  only, 
except  in  one  rare  instance  to  be  afterwards  noticed.  The  appli- 
cation of  the  hand,  in  some  cases,  communicates  sensations  diffe- 
rent from  those  of  mere  impulse;  and  suggests  to  us,  rather  than 
enables  us  actually  to  perceive,  the  existence  of  sound  within  the 
chest ;  but  this  confused  perception  cannot  bear  a  comparison 
with  that  supplied  by  the  stethoscope. 

In  ordinary  circumstances,  the  stethoscope,  applied  between 
the  cartilages  of  the  fifth  and  six  ribs,  at  the  end  of  the  sternum, 
or,  indeed,  in  any  point  where  the  pulsations  of  the  heart  are 
perceptible,  conveys  to  the  ear  a  distinct  sound ;  even  in  cases 
where  the  heart  is  very  small  and  weak,  and  when  the  pulse  is  no 
longer  to  be  perceived.  This,  in  the  healthy  body,  is  double  ; 
and  each  beat#  of  the  arterial  pulse  corresponds  to  this  double 
sound,  in  other  words,  to  two  sounds.  One  of  these  is  clear  and 
rapid,  and  somewhat  resembles  the  sound  produced  by  the  valve 
of  a  pair  of  bellows  :  this  corresponds  to  the  systole  of  the  auricles. 
The  other  is  more  dull  and  prolonged,  coinciding  with  the  beat 
of  the  pulse,  and  with  the  shock  or  impulse  communicated  to  the 
walls  of  the  chest  by  the  motion  of  the  heart ;  it  indicates  the 
contraction  of  the  ventricles.*     The  sounds   heard  at  the  end  of 

where  the  volume  of  the  heart  is  much  increased.  In  fact,  I  have  more  than 
once  had  occasion  to  observe  this  myself;  but  I  cannot  agree  with  M.  Jiouillaud 
in  supposing  that  this  dilatation  of  the  thoracic  walls  is  produced  in  such  cases, 
by  the  impulse  of  the  heart  against  them.  M.  BouiJlaud  regards,  as  an  analo- 
gous circumstance,  what  is  observed  to  take  place  in  aneurismal  tumors.  If 
this,  however,  were  the  true  cause  of  the  dilatation  of  the  parietes  of  the  tho-  * 
rax  in  these  cases,  it  appears  to  me  that  it  would  take  place  only  in  that  very 
portion  which  immediately  corresponds  to  the  point  of  the  heart,  as  it  is  this 
alone  which  imparts  the  impulse.  So  far  from  this,  on  the  contrary,  a  similar 
dilatation  is  found  to  take  place  in  cases,  even  where  no  impulse  is  perceptible, 
as  in  the  case  of  dropsy  of  the  pericardium,  and  also,  though  more  extended, 
in  pleuritic  effusions.  Now  in  all  these  different  circumstances,  must  not  one 
uniform  rule  be  applied,  which  provides  that  the  capacity  of  a  part  to  contain, 
shall  in  all  respects  correspond  to  the  dimensions  of  the  part  contained  ?  But, 
whatever  may  be  the  explanation  of  this  phenomenon,  its  existence  is  incontes- 
table, though  I  never  as  yet  have  observed  it  in  simple  concentric  hypertrophy. 

If,  indeed,  in  this  last  case,  it  can  be  shown  to  exist,  then  the  opinion  that  it 
is  occasioned  by  the  increased  impulse  of  the  heart,  would  not  be  without  foun- 
dation. And  yet  if  hypertrophy  of  the  heart,  without  enlargement  of  volume, 
should  exist  at  the  same  time  with  a  dilatation  of  the  corresponding  portion  of 
the  thoracic  walls,  a  space  would  be  left  between  these  walls  and  the  heart, 
a  matter  of  impossibility,  or  we  must  suppose,  in  order  to  supply  this  vacancy, 
that  a  certain  quantity  of  serum  is  thrown  out  into  the  pericardium,  sufficient 
to  distend  it,  in  the  same  way  that  the  pia-mater  supplies  the  deficiency  which 
exists  in  certain  cases  of  atrophy  of  the  brain.— Andral. 

*  The  isochronism  of  the  pulse  and  the  sounds  of  the  heart  which  correspond 
to  the  systole  of  the  ventricles,  had  generally  been  admitted  without  dispute, 
until  M.  Marc  d'Espine  of  Geneva,  by  a  series  of  very  careful  observations  un- 
dertook to  prove  that  the  pulsation  of' the  arteries  does  not  take  place  until  after 


OF    THE    SOUND. 


i8l 


the  sternum  are  produced  by  the  action  of  the  right  side  of  the 
heart ;  those  between  the  cartilages  of  the  ribs  by  the  left  cavities. 
In  the  state  of  health  the  sound  produced  by  the  contractions  of 
each  side  is  the  same  :  in  certain  states  of  disease,  on  the  contra- 
ry, the  sound  of  the  two  sides  becomes  quite  dissimilar. 

The  sound  is  the  only  phenomenon  usually  observable  in  any 
other  part  of  the  chest  beside  the  cardiac  region  ;  the  impulse  of 
its  action  being  confined,  as  already  observed,  to  the  space  com- 
prised between  the  cartilages  of  the  fifth  and  sixth  ribs,  the  end 
of  the  sternum,  or  (in  some  cases)  the  epigastrium.  The  sound 
produced  by  the  action  of  the  heart  is  great  in  proportion  as  the 
walls  of  the  ventricles  are  thin  and  their  impulse  feeble :  con- 
sequently, it  cannot  be  attributed  to  the  percussion  of  this  organ 
against  the  side.#  In  a  moderate  degree  of  hypertrophy,  the 
contraction  of  the  ventricles  yields  only  a  dull  sound,  like  the 
murmur  of  inspiration,  and  the  auricle,  in  like  manner,  much  less 
sound  than  in  the  natural  state.  In  a  high  degree  of  hypertrophy, 
the  contraction  of  the  ventricles  produces  merely  a  shock  without 
any  sound,  and  the  sound  of  the  auricles  becomes  very  dull  and 
is  scarcely  audible.  On  the  other  hand,  when  the  ventricular 
parietes  are  thin,  the  sound  produced  by  their  contraction  is  clear 
and  loud,  approaching  to  that  of  the  auricles  ;  and  if  there  be  a 
marked  dilatation  of  the  ventricles,  the  sound  becomes  nearly 
similar,  and  almost  as  strong  as  that  of  the  auricles.  In  the  case 
of  considerable  dilatation,  the  two  sounds  can  be  distinguished, 

the  impulse  of  the  heart  has  been  perceived.     The  following  are  the  results  of 
my  observations  upon  this  subject. 

When  the  pulsations  of  the  heart  are  of  their  ordinary  frequency,  the  im- 
pulse of  the  radial  artery  as  appreciated  by  the  finger,  is  simultaneous  with  the 
impulse  of  the  heart  as  perceived  by  the  ear.  The  same  is  true  in  regard  to  the 
arteries  of  the  face  and  thigh.  But  as  it  respects  the  arteries  of  the  foot,  in 
which  according  to  M.  Marc  d'Espine,  the  anachronism  of  the  pulsations  of  the 
heart  and  arteries  can  be  more  easily  perceived,  it  does  not  appear  to  me  that  it 
differs  from  the  other  arteries  which  have  been  mentioned.  Nevertheless,  in 
cases  where  the  pulsations  of  the  heart  are  slow,  or  do  not  amount  to  more  than 
sixty  in  a  minute,  the  fact  announced  by  M.  Marc  d'Espine  may  be  readily  as- 
certained, particularly  in  the  arteries  of  the  foot.  Under  such  circumstances,  I 
have  frequently  assured  myself  that  pulsations  of  the  arteries  of  the  foot  imme- 
diately followed  the  impulse  of  the  heart;  that  is  to  say,  during  the  moment  of 
repose  wffSich  takes  place  in  the  heart  between  the  first  and  second  sound.  In 
a  series  of  experiments  conducted  by  an  association  of  medical  gentlemen  in 
Dublin,  upon  the  movements  of  the  heart,  they  have  also  proved  that  the  pul- 
sation of  all  the  arteries  is  not  synchronous  with  the  contraction  of  the  ventri- 
cles of  the  heart,  being  lets  ao  I  lie  farther  they  are  from  the  heart.  Thus,  by 
puncturing  at  the  same  time  the  pulmonary  artery  and  the  right  ventriHe,  the 
two  jets  of  blood  are  found  to  take  place  at  the  same  moment.  In  repeating 
the  same  experiment  upon  one  of  the  mesenteric  arteries,  the  result  was  differ- 
ent; the  jet  from  the  artery  took  place  a  little  after  that  from  the  puncture  in 
the  ventricle. — Andral. 

*  It  will  be  seen  hereafter  that  one  of  the  most  distinguished  physiologists  of 
the  age,  M.  Majendie,  nevertheless,  still  adheres  to  this  most  ancient  and  popu- 
lar explanation  of  the  phenomenon—  Transl. 


582  EXPLORATION  OF  THE  HEART. 

neither  by  their  character  nor  their  degree,  but  solely  by  their 
isochronism  or  anachronism  with  the  arterial  pulse.  In  a  state 
of  health  the  sound  of  the  contractions  of  the  heart  is  nowhere 
heard  so  strongly  as  in  the  cardiac  region ;  and  it  becomes  feebler 
in  the  other  points  of  the  chest  according  to  the  progression  for- 
merly mentioned.  But  in  certain  cases  of  disease  it  may  be  heard 
more  distinctly  in  other  places.  In  dilatation  of  the  ventricles 
the  sound  of  the  heart's  contractions  is  commonly  as  loud  under 
the  clavicles  as  in  the  cardiac  region. 

In  certain  healthy  subjects,  in  whom  the  walls  of  the  heart  are 
somewhat  thinner  than  common,  the  sound  of  the  contraction  of 
the  auricles  is  sometimes  much  louder  than  that  of  the  ventricles 
below  the  clavicles,  although  the  same  disproportion  is  not  ob- 
served in  the  cardiac  region.  In  cases  of  hypertrophy,  also,  it 
frequently  happens  that  while,  in  the  cardiac  region,  we  are  sen- 
sible only  of  a  strong  impulse  with  hardly  any  sound,  even  of  the 
auricles,  the  latter  is  perceptible  (and  this  only)  under  the  clavi- 
cles, and  even  on  the  back.  Indeed,  even  in  slighter  cases  of 
hypertrophy,  the  sound  of  the  auricles  is  always  more  distinct  in 
these  places  than  in  the  region  of  the  heart,  particularly  in  lean 
and  narrow-chested  subjects.  In  certain  cases  both  the  sounds, 
although  sufficiently  distinct,  become  extremely  dull  in  the  region 
of  the  heart.  Sometimes  this  dullness  depends  on  the  natural 
prolongation  of  the  lungs  and  pleura,  over  and  above  the  heart. 
In  this  case  the  sound  of  the  respiration  sometimes  prevents  us 
from  distinguishing  clearly  the  sound  of  the  heart ;  and  the  con- 
traction of  the  ventricles,  in  pressing  out  the  air  from  the  portions 
of  lung  situated  between  them  and  the  sternum,  always  produces 
a  particular  sound,  which  will  be  noticed  below,  and  which  occa- 
sionally altogether  masks  the  natural  sound. 

It  may  be  well  to  remark  in  this  place0  that  the  disposition  of 
lung  just  mentioned,  and  which  is  by  no  means  uncommon,  may 
sometimes  render  null  one  of  the  signs  considered  as  indicating 
enlargement  of  the  heart, — I  mean  the  dead  sound  on  percussion. 
In  such  cases  the  cardiac  region  will  yield  a  good  sound,  although 
the  heart  may  be  double  the  natural  size :  this  is  chiefly  observed 
in  the  instance  of  pulmonary  emphysema  complicated  with  dis- 
eased heart — a  complication  not  very  unusual.  Softening  of  the 
substance  of  the  heart,  an  affection  which,  although  very  frequent, 
has  hitherto  been  little  attended  to  by  practitioners,  appears  also 
to  render  the  sound  of  the  heart  much  duller  than  natural.  And, 
lastly,  the  obstruction  of  the  natural  flow  of  blood  through  the 
heart,  whether  produced  by  too  much  blood,  or  by  disease  of  the 
lungs,  not  only  diminishes  but  modifies  the  sound.  Other  and 
very  remarkable  modifications  of  sound  presented  by  the  heart  in 


OF    THE    RYTHM. 


583 


il£  different  pathological  states,  will  be  noticed  in  a  subsequent 
chapter.* 


CHAPTER  IV. 

OF    THE    RYTHM    OF    THE    PULSATIONS    OF    THE    HEART. 

By  rythm  I  understand  the  order  of  the  contractions  of  different 
parts  of  the  heart,  and  their  relative  duration  and  succession,  as 

*  Since  Laennec  called  the  attention  of  physicians  to  the  sounds  of  the  heart, 
and  to  the  results  of  his  researches  upon  this  subject,  various  attempts  have  been 
made  to  ascertain  the  cause  of  these  sounds.  In  fact  Laennec  himself  said 
nothing  definite  upon  this  point,  being  satisfied  in  merely  pointing  out  the  dif- 
ferent conditions  of  the  heart  which  appeared  to  modify  these  sounds.  The 
first  sound  he  proved  to  be  isochronous  with  the  impulse  of  the  heart  and  arte- 
ries,, and  consequently  to  coincide  with  the  systole  of  the  ventricles.  The 
second  sound,  on  the  contrary,  he  alsoshowe  1  to  be  coincident  with  the  diastole 
of  the  ventricles  and  the  systole  of  the  auricles  ;  but  he  has  never  said,  as  some 
have  alleged,  that  the  first  sound  was  produced  by  the  contraction  of  the  ven- 
tricles and  the  second  by  the  contraction  of  the  auricles. 

A  great  variety  of  theories  have  been  set  forth  in  order  to  account  for  the  dif- 
ferent sounds  of  the  heart. 

One  writer  has  attributed  them  to  the  contraction  of  the  cavities  of  the  heart; 
a  second  has  found  a  cause  in  the  blood  ;  a  third  has  regarded  the  valves  as  the 
principal  agents  in  their  development ;  and  finally  an  attempt  has  been  made 
to  explain  them  by  the  impulse  of  the  heart  against  the  walls  of  the  chest. 
We  shall  take  a  cursory  view  of  each  of  these  theories. 

M.  Marc  d'Espine,  after  having  shown  with  Laennec  that  the  first  sound  coin- 
cided with  the  systole  of  the  ventricles,  and  the  second  with  that  of  the  auricles, 
also  attempted  to  prove  that  the  true  cause  of  both  these  sounds  resided  in  the 
ventricles.  Assuming  as  a  fact  that  every  muscle,  in  contracting,  produces  a 
certain  sound,  he  inferred  that  the  contraction  of  the  ventricles  must  cause  the 
first  sound  of  the  heart,  but  at  the  same  time  denied  that  the  contraction  of  the 
auricles  could  produce  the  second  sound  ;  and  he  assures  us  that  he  never  could 
discover  that  the  contraction  of  the  auricles  was  any  other  than  a  sort  of  a  ver- 
micular movement  in  every  respect  incapable  of  producing  the  sound  which 
coincided  with  the  dilatation  of  the  ventricles. 

What  then  is  the  cause  of  the  second  sound  of  the  heart  ?  M.  Marc  d'Espine 
thinks  that  the  dilatation  as  well  as  the  contraction  of  the  ventricles  is  an  active 
phenomenon  ;  and  in  fact  M.  Magendie,  long  since  noticed  that  a  peculiar  sen- 
sation of  resistance  was  experienced  in  attempting  to  arrest  the  dilatation  of  the 
ventricles  by  compressing  the  heart. 

Supported  by  this  fact,  M.  Marc  d'Espine  has  considered  the  dilatation  of  the 
ventricles  the  cause- of  the  second  sound  ;  and  the  fact  that  it  is  heard  higher  up 
than  the  first  is  owing,  he  thinks,  to  the  falling  back  of  the  ventricles  from  the 
thoracic  walls.  Other  experimenters,  beside  M.  d'Espine  have  also  shown  that 
the  contraction  of  the  auricles  and  ventricles  is  very  different.  M.  Bouillaud, 
in  studying  the  movements  of  the  heart  in  a  cock  in  which  he  had  laid  this  or- 
gan bare,  also  assures  us  that  no  distinct  contraction  of  the  auricles  could  be 
perceived  by  the  eye  or  touch.  In  two  rabbits  only  has  he  seen  the  auricles 
contract,  and  in  these  very  feebly ;  and  adds  M.  Bouillaud,  then  the  auricles  did 
not  become  rigid  like  the  ventricles  ;  the  contraction  of  the  auricular  appendi- 
ces being  the  most  distinct,  as  is  also  remarked  by  M.  d'Espine. 

The  friction  of  the  blood  over  the  internal  surfaces  of  the  heart,  has  been 
regarded  by  31.  Pigeaux  as  the-  cause  of  the  sounds  which  arise  from  this  organ 


584  EXPLORATION  OF  THE  HEART. 

detected  by  the  stethoscope.  I  shall  describe  in  order  the  differ- 
ent sounds  produced  by  a  heart  in  a  perfectly  healthy  state,  and 

during  its  action.  The  first  sound,  according  to  him,  is  hoard  at  the  instant  the 
blood,  escaping  from1  the  auricles,  strikes  upon  the  inner  surface  of  the  walls  of  the 
ventricles;  the  second  sound  he  heard,  at  the  moment  when  the  blood  issuing 
from  the  ventricles,  enters  and  courses  along  the  walls  of  the  aorta  and  pulmo- 
nary artery.  Supposing  then  that  the  friction  of  the  blood  against  the  walls  of 
the  cavities  through  which  it  passes,  has  some  influence  in  producing  the  sounds 
of  the  heart,  it  is  impossible,  as  M.  Pigeaux  would  have  it,  that  the  first  sound 
coincides  with  the  influx  of  blood  into  the  ventricles,  as  it  has  been  demonstra- 
ted that  the  first  sound  is  synchronous  with  the  systole  of  the  ventricles. 

Dr.  Hope  thinks  that   the  first    sound  is  caused    by  the    impulse  of  the  blood 
against  the  walls  of  the  ventricles,  and  the   agitation  which  it  surfers  in  its  pas- 
sage from  the  ventricles  through  the  orifices  of  the  aorta  and  pulmonary  artery. 
He  accounts    for  the    second  sound  by  the  reaction   of  the    ventricular  walls 
upon  the  mass  of  blood  which  has  escaped  into  them  during  their  dilatation. 

Another  theory  has  been  proposed  by  M.  Rouanet  which  differs  in  every  re- 
spect from  the  preceding.  According  to  him,  the  sounds  of  the  heart  are  pro- 
duced by  the  action  of  the  valves  of  this  organ.  Hence  M.  Bouillaud,  who  has 
adopted  with  some  slight  modifications,  the  theory  of  M.  Rouanet,  proposes 
that  the  double-sound  which  the  heart  produces  in  its  normal  state,  should  be 
called  the  vfllvular  sound,  (bruit  valvulaire)  in  order  to  distinguish  it  from  other 
sounds  which  are  heard  only  in  certain  pathological  conditions  of  the  organ. 
On  this  theory  the  first  sound  is  regarded  as  nothing  more  than  what  must  ne- 
cessarily follow  from  the  sudden  collapse  of  the  auriculo-ventricular  valves  du- 
ring the  systole  of. the  ventricles.  M.  Bouillaud  also  thinks  that  the  sudden 
relapse  of  the  sigmoid  valves  against  the  arterial  walls,  may  likewise  have 
some  influence  in  the  production  of  the  first  sound  of  the  heart. 

The  second  sound,  according  to  Rouanet,  is  owing  to  the  sudden  reflux  of  the 
column  of  blood  which  is  received  in  the  arteries,  against  the  sigmoid 
valves.  M.  Bouillaud  inclines  to  the  opinion  that  the  second  sound  is  equally 
dependant  upon  the  relapse  of  the  auriculo-ventricular,  and  the  collapse  of  the 
arterial  valves.  He  would  not  deny  that  the  reflux  of  blood  upon  the  arterial 
valves  may  have  some  influence  in  producing  this  sound,  but  states  he  does  not 
think  it  the  sole  cause.  He  would  superadd  to  this  some  influence  which  the 
movements  of  the  valves  may  also  have. 

M.  Magendie,  from  experiments  sufficiently  often  repeated  to  insure  the  ac- 
curacy of  their  results,  has  shown  that  the  sounds  of  the  heart  are  simply  the 
result  of  the  impulse  of  this  organ  against  the  thoracic  walls.  If  indeed,  as 
has  oftentimes  been  done  by  himself,  these  walls  be  raised,  and  the  ear  be  ap- 
plied to  the  naked  heart,  no  sound  is  heard,  unless  the  heart  strikes  upon  some 
of  the  surrounding  parts. 

According  to  this  distinguished  physiologist,  the  first  sound  depends  upon 
the  shock  which  the  heart  produces  against  the  intercostal  spaces  contiguous  to 
it,  and  the  second  corresponds  to  the  dilatation  of  the  ventricles  and  consequently 
to  the  sudden  escape  of  blood  into  these  cavities.  The  superior  degree  of  clearness 
of  the  second  sound  over  the  first,  is  owing,  according  to  M.  Magendie,  to  the 
very  considerable  bulk  of  the  impellent  body  on  the  one  hand,  and  to  the  nature 
of  the  body  against  which  its  force  is  spent  on  the  other.  This,  (the  sternum) 
in  consequence  of  its  solidity,  renders  the  sound  much  more  distinct  and  clear 
than  the  lateral  walls  of  the  thorax  could  do,  being  for  the  most  part  composed 
of  muscle. 

M.  Magendie  introduced  through  the  walls  of  the  chest  two  small  moveable 
probes,  one  upon  the  right  and  the  other  upon  the  left  ventricle,  and  he  assures 
us  that  each  sound  of  the  heart  was  accompanied  with  a  shock  or  impulse 
which  manifested  itself  without,  by  a  corresponding  movement  of  the  probes. 

This  theory  seems  to  me  to  account  for  certain  pathological  facts,  in  a  much 
more  satisfactory  manner  than  that  of  M.  Rouanet.  I  never  could  conceive, 
for  example,  how  by  this  theory,  we  could  account  for  the  fact,  that  in  hypertrophy 
of  the  ventricular  walls,  the  intensity  of  the  first  sound  is  diminished,  and  in 
dilatation  of  these  walls,  is  increased. 


OF    THE    RYTHM. 


585 


in  the  best  proportions  for  executing  its  functions  with  freedom 
and  integrity.     It  is  not  possible  to  state  these  proportions  with 

On  the  contrary,  the  theory  of  M.  Magendie  explains  the  thing  at  once, 
which,  properly  speaking,  is  in  fact,  no  more  nor  less  than  what  belongs  to 
certain  pathological  states.  For  if  indeed,  it  is  the  density  of  the  body  afford- 
ing the  shock,  which  renders  the  first  sound  less  distinct  than  the  second,  then 
we  can  easily  conceive  how  that  in  proportion  as  this  density  increases,  the 
more  dull  and  obscure  will  the  second  sound  become. 

The  opinion  of  M.  Magendie  upon  the  sounds  of  the  heart  is,  then,  the  one 
which  I  have  most  willingly  adopted.  It  is  proper,  however,  that  I  should  here 
refer  also  to  the  experiments  of  MM.  Bouillaud  and  Hope,  the  results  of  which 
are  just  the  opposite  of  those  of  M.  Magendie. 

In  these  experiments,  the  two  distinguished  gentlemen  whom  I  have  just 
named,  having  raised  the  walls  of  the  thorax  in  different  animals,  and  laid  bare 
the  heart,  assure  us  that  they  could  distinctly  hear  the  'two  sounds  of  the  heart. 
New  observations  will  undoubtedly  bring  to  light  certain  circumstances,  which 
are  the  true  cause  of  the  difference  in  the  results  of  the  experiments  of  M. 
Magendie  on  the  one  hand,  and  those  of  MM.  Bouillaud  and  Hope  on  the  other. 
Finally,  before  closing  this  note,  I  shall  extract  from  the  Ency  do  graphic  des 
Sciences  Mfdieales  (for  Jan.  1836,)  the  translation  which  is  there  given  of  a 
Report  read  before  the  British  Medical  Association,  Aug.  11,  1835,  in  the  name 
of  a  Commission  formed  at  Dublin,  for  the  purpose  of  making  some  researches 
upon  the  successive  movements  of  the  different  portions  of  the  heart,  and  upon 
the  sounds  which  accompany  these  movements.  I  shall  here  transcribe  only 
that  portion  of  the  Report  which  relates  to  the  sounds. 

First  Experiment.  In  applying  the  stethoscope  to  the  cardiac  region  of  a  calf 
in  which  an  artificial  respiration  was  kept  up,  the  two  sounds  of  the  heart  were 
distinctly  heard.  The  first,  prolonged  and  obscure  ;  the  second,  short  and 
clear.  The  sternum  and  ribs  were  then  raised,  and  care  taken  that  the  heart 
should  no  where  be  in  contact  with  the  thoracic  walls.  A  stethoscope,  fur- 
nished with  a  flexible  tube,  was  then  applied  to  the  pericardium  over  the  region 
corresponding  to  the  ventricles,  and  the  two  sounds  of  the  heart  were  again 
distinctly  heard. 

By  placing  the  ear  near  to  the  heart,  without,  however,  touching  it,  both 
sounds  were  in  like  manner  heard,  though  less  distinct.  A  smalt  piece  of 
pasteboard  was  then  placed  over  the  ventricles,  and  the  stethoscope  was  again 
applied  to  the  surface  of  the  pasteboard,  and  again  the  two  sounds  were  heard 
a3  distinctly'  and  almost  as  clearly  as  through  the  sternum.  When  the  stethos- 
cope was  applied  to  the  ventricles,  near  their  point,  the  first  sound  was  very 
distinctly  heard;  the  second,  on  the  contrary,  was  scarcely  audible.  When 
applied  above  the  origin  of  the  large  arteries,  both  sounds  were  quite  distinct, 
but  more  particularly  the  second.  The  pericardium  being  distended  with  water, 
both  sounds  were  heard,  not  so  distinct,  however,  as  before  the  injection. 

Second  Experiment.  After  having  raised  in  a  calf,  as  before,  not  only  the 
sternum  and  ribs,  but  also  the  pericardium,  the  two  sounds  of  the  heart  were 
explored  by  means  of  the  stethoscope  applied  to  different  parts  of  the  ventricles, 
and  the  result  was  precisely  the  same  as  in  the  first  experiment.  On  compress- 
ing the  large  arteries  near  the  heart,  the  character  of  the  sound  was  altered.  *  *  *  * 
A  very  fine  curved  needle  was  introduced  through  the  aorta,  and  also  one 
through  the  pulmonary  artery  just  below  the  line  where  the  semi-lunar  valves 
are  attached  to  these  vessels,  which  being  carrried  about  one  half  of  an  inch 
above,  were  again  brought  out  of  the  vessels  in  such  a  manner,  that  one  of  the 
valves  should  be  engaged  between  each  needle  and  the  walls  of  the  artery. 
The  stethoscope  was  then  applied  to  the  origin  of  the  arteries,  and  it  was  found 
that  the  second  sound  had  ceased,  and  that  only  one  sound  was  heard,  which 
resembled  the  first  sound,  and  coincided  with  the  systole  of  the  ventricles. 

Third  Experiment.  A  repetition  of  the  first, — except  that  the  needle  only 
having  been  partially  fixed,  every  time  that  valve  disengaged  itself  the  second 
sound  returned. 

Fourth  Experiment.  The  heart  was  taken  from  the  thorax  of  a  calf  and 
placed   upon  a  table.     On   applying  the  stethoscope  to  the  ventricles,  at  each 

74 


586  EXPLORATION  OF  THE  HEART. 

geometrical  accuracy  :*  but  I  am  led  by  the  result  of  all  my  dis- 
sections since  the  year  1801,  to  fix  them  as  follows  : — The  heart, 

systole  one  sound  only  was  heard,  which  corresponded  to  what  is  called  the  first 
sound.  When  the  heart  had  ceased  to  heat,  the  semi-lunar  valves  were  cut 
away,  and  the  ventricles  filled  with  water.  Supporting  the  hear!  in  a  vertical 
position  and  applying  the  stethoscope  to  the  ventricles,  while  they  were  com- 
pressed with  the  hand  in  such  a  manner  that  the  water  should  he  driven  through 
the  arterial  trunks,  a  sound  was  heard  resembling  the  first  sound.  The  hand 
being  suddenly  relaxed,  a  similar  sound  was  again  heard.  On  applying  the 
instrument  to  the  empty  ventricles  of  the  heart,  disengaged  from  the  body,  and 
rubbing  together  its  internal  surfaces,  a  sound  was  produced  which  somewhat 
resembled  the  first  sound. 

The  finger  introduced  into  the  left  ventricle  through  the  amiculo-vcntricular 
orifice,  and  rubbed  gently  over  its  internal  surface,  produced  a  sound  resembling 
the  first  sound,  which  was  heard  by  means  of  the  stethoscope  placed  upon  the 
ventricles.  Drops  of  water  which  were  made  to  fall  from  a  considerable  height 
through  a  glass  tube  upon  the  semi-lunar  valves  of  the  aorta,  produced  a  sound 
very  similar  to  the  second  sound.  Introducing  the  tube  between  the  vah  es  and 
moving  it  alternately  in  and  out,  a  sound  was  produced  resembling  the  rasp 
sound,  (bruit  de  rape.) 

The  committee,  from  these  different  experiments,  have  come  to  the  following 
conclusions  : — 

1st.  The  sounds  of  the  heart  are  not  produced  by  the  contact  of  the  ventricles 
with  the  sternum  or  ribs  ;  but  they  are  the  result  of  the  internal  movements  of 
the  heart  and  its  vessels. 

2nd.  The  sternum  and  the  anterior  walls  of  the  thorax,  by  their  contact  with 
the  ventricles,  enhance  the  clearness  of  these  sounds. 

3d.  The  first  sound  corresponds  to  the  ventricular  systole,  both  in  its  com- 
mencement and  duration. 

4th.  The  cause  of  the  first  sound  is  co-existent  with  the  systole  of  the  ven- 
tricles. 

5th.  The  first  sound  does  not  depend  upon  the  closing  of  the  auriculo-ventric- 
ular  valves  at  the  commencement  of  the  systole,  for  this  action  of  the  valves 
takes  place  only  at  the  commencement  of  the  systole,  and  does  not  endure  so 
long  as  the  systole. 

6th.  The  first  sound  is  not  produced  by  the  friction  of  the  internal  surfaces 
of  the  ventricles  against  each  other;  for  it  is  impossible  that  this  should  take 
place  before  the  blood  is  driven  from  the  ventricles,  while  the  first  sound  is 
simultaneous  with  the  commencement  of  the  ventricular  systole. 

7th.  The  first  sound  is  produced  either  by  the  rapid  movement  of  the  blood 
over  the  internal  and  irregular  surfaces  of  the  ventricles  in  its  passage  to  the 
arterial  orifices,  or  by  the  bruit  musculairc  of  the  ventricles,  or,  which  is  most 
probable,  by  the  operation  of  both  of  these  causes  at  once. 

8th.  The  second  sound  coincides  with  the  termination  of  the  ventricular  sys- 
tole. It  is  necessary  to  its  production  that  the  arterial  valves  be  in  a  healthy 
state.  This  sound  seems  to  be  caused  by  the  sudden  resistance  which  these 
valves  offer  to  the  column  of  blood  which  is  thrown  back  by  the  elasticity  of 
the  arterial  trunks,  toward  the  heart  after  eacli  systole  of  the  ventricles. 

The  committee  have  concluded  their  report  by  declaring  that,  notwithstand- 
ing all  the  researches  which  have  already  been  made  to  determine  the  nature 
and  cause  of  the  sounds  of  the  heart,  the  subject  is  yet  far  from  being  exhaust- 
ed ;  and  in  order  to  settle  the  question  completely,  further  observations  must 
yet  be  made.  I  share  in  their  opinion  ;  and  I  believe,  moreover,  that  the  cause 
of  the  sounds  of  the  heart  is  not  a  simple  one,  and  it  seems  to  me  that  among 
all  the  different  causes  to  each  of  which  these  sounds  have  been  exclusively  at- 
tributed, there  is  none  which  does  not  have  some  share  in  their  production, 
while  on  the  other  hand,  no  one  is  a  sufficient  cause  of  itself. — And  nil. 

*  Many  physiologists  have  expended  much  time  and  labor  in  determining  the 
weight  and  dimensions  of  the  heart,  in  the  hope,  if  possible,  of  arriving  at  some 
result  by  which  the  precise  point  of  departure  from  a  healthy  to  a  pathological 
state  might  be  ascertained. 


OF    THE    RYTHM.  587 

including  the  auricles,  ought  to  be  of  a  size  equal  to  the  closed 
hand  of  the  subject,  or  only  a  little  less  or  greater  than  it.     The 

In  relation  to  the  weight,  the  following  are  the  principal  results  which  have 
been  obtained;  and  they  unfortunately  differ  so  much,  that  the  necessity  for 
other  and  new  observations  is  plainly  indicated. 

M.  Lobstien  has  fixed  the  weight  of  the  adult  heart,  in  its  healthy  state,  at 
from  9  to  10  ounces  ;  M.  13ouillaud  from  8  to  9,  and  M.  Cruveilhier  from  6  to 
7  only. 

The  weight  of  the  heart  cateris  ■paribus,  is  in  direct  ratio  to  the  size  and  con- 
stitution of  the  individual.  Thus  in  a  very  large  and  strongly  constituted  indi- 
vidual, who  had  never  manifested  any  signs  of  an  affection  of  the  heart,  M. 
Bouillaud  found  the  weight  of  the  heart  to  be  11  ounces.  In  comparing  the 
mean  weight  of  the  heart  in  its  normal  state  with  its  mean  weight  in  a  state  of 
hypertrophy  or  atrophy,  the  same  learned  professor  arrives  at  the  following 
interesting  result,  viz  :  that  the  weight  of  the  heart  in  a  state  of  extreme  hyper- 
trophy is  more  than  quintuple  of  its  weight  in  extreme  atrophy,  and  nearly 
triple  of  its  weight  in  a  normal  state. 

According  to  M.  Bouillaud,  the  weight  of  the  heart  in  an  extreme  state  of 
hypertrophy  is  from  24  to  27  ounces.  M.  Lobstein  assures  us,  however,  that  he 
has  seen  a  heart  in  this  condition  which  weighed  32  ounces. 

In  relation  to  the  dimensions  of  the  heart,  the  following  are  its  measurements 
in  its  natural  and  healthy  condition,  either  considered  as  a  whole  or  in  separate 
parts,  as  laid  down  by  M.  Bouillaud. 


fyches.      Lines. 
8  9i 

10  6 


Circumference  of  the  heart  at  the  base  of)  »» 

the  ventricles )„. 

( Min.  " 

C  Mean  3  7$ 

Length 2  Max.  4  " 

( Min.  3  2\ 

C  Mean  2  7i 

Breadth ?  Max.  4  6* 

(Min.  3  5 

r  Mean  1  n£ 

Thickness ?  Max.  2  7 

( Min.  1  5 

Thickness  of  the  walls  of  the  left  ven-  ^  j^ean  £* 

tricle ^;ax-  J  f 

(  Min.  0  5 


0  2f 

0  3J 


Thickness  of  the  walls  of  the  right  ven-  \  »,, 

tricle  -         -         -         -         -         -    >  M.  *  ' 

( Min.  0  li 

Thickness  of  the  inter-ventricular  septum  0  11 

Thickness  of  the  walls  of  the  left  au-  \  ««■ 


o  u 

0  2 


(Mm,  0  «l 

C  Mean  0  1 

Thickness  of  the  walls  of  the  right  auricle  <  Max.  0  1| 

( Min.  0  "J 

Circumference  of  the  left  auriculo-ven-  S  » 
.  •      i  .c  <  Max. 

tricular  orifice  -         -         -         -         -    J  n* 


Circumference  of  the  right  auriculo-ven-  l  .j 

tricular  orifice /  iw-  n 


3  6i 

3  10 

3  3 

3  10 


Circumference   of   the  ventriculo-aortic 
orifice , 


Circumference  of  the  ventriculo-pulmo-  j  ,. 

nary°r,fice (Min.  2  6 


3  9 

2  5± 

2  8 

2  4 

2  7| 

2  10 


588  EXPLORATION  OF  THE  HEART. 

walls  of  the  left  ventricle  ought  to  be  of  a  thickness  somewhat 
more  than  double  that  of  the  right.  The  texture  of  the  left  ven- 
tricle, firmer  and  more  compact  than  that  of  the  muscles,  ought 
to  keep  it  from  collapsing  when  laid  open.  The  right  ventricle 
ought  to  be  a  little  larger  than  the  left,  with  columnar  carnae  of 
greater  size,  and  ought  to  collapse  on  being  cut  into.* 

In  a  heart  so  proportioned,  the  alternate  contractions  of  the 
ventricles  and  auricles,  as  examined  by  the  stethoscope,  and  the 
pulse  as  examined  by  the  finger,  afford  the  following  results : — 
At  the  moment  of  the  arterial  pulse,  the  ear  is  slightly  elevated 
by  an  isochronous  motion  of  the  heart,  which  is  accompanied  by 
a  somewhat  dull,  though  distinct  sound.  This  is  the  contraction 
of  the  ventricles.  Immediately  after,  and  without  any  interval, 
a  louder  sound  resembling  that  of  a  valve,  or  a  whip,  or  the  lap- 
ping of  a  dog,  announces  the  contraction  of  the  auricles.  (I  make 
use  of  these  trivial  expressions  because  they  appear  to  me  to  con- 
vey better  than  any  description,  an  idea  of  the  nature  of  the  sound 
in  question.)  This  sound  is  accompanied  by  no  motion  percep- 
tible by  the  ear,  and  is  separated  by  no  interval  of  repose  from 
the  duller  sound  and  motion  indicative  of  the  contraction  of  the 
ventricles,  which  it  seems,  as  it  were,  to  terminate  and  interrupt 
abruptly.  The  duration  of  this  sound,  and  consequently  the 
period  of  contraction  of  the  auricles,  is  less  than  that  of  the  ven- 
tricles— an  incontestable  fact  of  which  Haller  entertained  doubts. 
Immediately  after  the  systole  of  the  auricles,  there  is  a  very  short, 
yet  well  marked  interval  of  repose,  subsequently  to  which  we  feel 
the  ventricles  swell  anew,  with  the  dull  sound  and  gradual  pro- 
gression which  characterize  their  action  ;  then  follows  the  quick 
and  sonorous  contraction  of  the  auricles,  and  again  the  renewed 
but  momentary  quiescence  of  the  heart.  This  state  of  quietude 
after  the  contraction  of  the  auricles,  does  not  appear  to  have  been 
known  to  Haller  as  a  natural  condition.!     The  relative  duration 

I  have  for  quite  a  number  of  years,  also  devoted  myself  to  similar  researches, 
and  I  have,  with  one  exception,  uniformly  obtained  results  similar  to  those  of 
M.  Bouillaud.  The  mean  thickness  of  the  inter-ventricular  septum,  though  fre- 
quently measured  by  myself,  has  never  exceeded  more  than  a  line;  the  thick- 
ness of  the  walls  of  the  left  ventricle,  which  is  much  below  the  mean  thickness 
as  laid  down  by  M.  Bouillaud,  viz.,  1 1  linos. — Andtal. 

The  thickness  of  the  walls  of  the  left  ventricle  is  more  frequently  triple 
than  double  that  of  the  right.  This  proportion,  however,  only  obtains  in  the 
adult.  In  infancy  this  is  still  greater.  Prom  ibis  epoch  until  puberty,  it  gradu- 
ally diminishes.  Through  the  whole  period  of  ;ulult  life  it  remains  about  the 
same,  and  in  old  age  it  increases  again. — Andral. 

t  This  explanation  of  the  progressive  movements  or  rythm  of  the  heart  is,  as 
stated  in  a  former  note,  ai  variance  with  the  observations  and  opinions  of  nearly 
all  preceding  and  succeeding  physiologists,  and  cannot  be  entertained  in  the 
present  state  of  our  knowledge.  The  precedence  of  the  auricular  to  the  ven- 
tricular contraction,  longsince  observed  by  Harvey  and  Haller,  has  been  satis- 
factorily established  by  the  recent  experiments  of  Dr.  Hope  :  and  I  would  give 
the  following  statement,  from   the  article  Auscultation  in   the  Cyclopaedia,  as  an 


OF    THE    RYTHM. 


589 


of  the  contractions  of  the  auricles  and  ventricles,  appears  to  me 
to  be  as  follows  : — a  third  (at  most)  or  a  fourth  is  occupied  by 
the  systole  of  the  auricles  ;  a  fourth,  or  a  little  less,  by  the  state 
of  quiescence,  and  the  half,  or  nearly  so,  by  the  systole  of  the 
ventricles. 

These  remarks  may  seem  minute ;  but  I  am  assured  they  will 
be  found  exact  and  easily  verified  by  any  one  who  will  attend  to 
the  action  of  the  heart,  in  a  healthy  subject,  for  only  a  few  minutes ; 
and  such  trial  will  be  made  with  most  advantage  when  the  pulse 
is  slow.  When  the  pulse  is  at  the  same  time  slow  and  infrequent, 
the  contraction  of  the  ventricles  is  prolonged,  the  sound  duller, 
and  the  shock  less:  the  systole  of  the  auricles,  however,  still 
retains  its  wonted  brevity  and  sound, — or  even  appears  shorter 
than  usual,  on  acount  of  the  lengthened  systole  of  the  ventricles. 
In  this  case,  the  interval  of  repose  after  the  contraction  of  the 
auricle  is  not  sensibly  shorter.  The  period  of  quiescence  after 
the  contraction  of  the  auricle,  is  not  sensibly  less.  When,  how- 
ever, the  pulse  is  infrequent  and  at  the  same  time  quick,  the  in- 
terval of  repose  is  then  longer  and  more  marked  than  usual.  In 
the  case  of  a  person  laboring  under  apoplexy,  whose  pulse,  though 
quick,  was  only  fifty-eight  in  a  minute,  I  found  it  equal  to  the 
period  of  the  systole  of  the  ventricles ;  and  in  another,  with 
symptoms  of  the  same  disease  impending,  with  a  pulse  also  quick 
and  only  forty  in  the  minute,  the  period  of  quiescence  was  equal 
to  that  of  the  systole  of  both  the  auricle  and  ventricle. 

From  the  foregoing  observations  it  appears  that  the  heart,  far 
from  being  in  a  state  of  constant  action,  as  is  usually  supposed, 
presents  alternations  of  action  and  repose,  the  sum  of  which  does 
not  differ  from  those  of  many  other  muscles,  more  especially  the 

accurate  representation  of  the  phenomena,  in  opposition  to  that  in  the  text : — 
The  first  motion  of  the  heart  which  interrupts  the  interval  of  repose,  is  the 
auricular  systole.  It  is  a  very  slight  and  brief  contractile  movement,  more 
considerable  in  the  auricular  appendix  than  elsewhere,  and  propagated  with  a 
rapid  vermicular  motion  towards  the  ventricle,  in  the  systole  of  which  it  ter- 
minates rather  by  continuity  of  action  than  by  the  succession  of  a  new  move- 
ment. The  ventricular  systole  commences  suddenly,  and  is  accompanied  with 
a  considerable  diminution  of  the  volume  of  the  organ.  Synchronous  with  the 
systole  are  the  first  sound,  the  impulse  of  the  apex  against  the  ribs,  and  the  pulse 
in  vessels  near  the  heart :  in  the  radials  the  pulse  follows  at  a  barely  appreciable 
interval.  The  systole  of  the  ventricles  is  followed  by  their  diastole,  during 
which  they  return,  by  an  instantaneous  expansive  movement  sensible  to  the 
touch  and  sight,  to  the  same  state  (with  respect  to  size,  shape,  position,  &c.)  as 
during  the  previous  interval  of  repose.  This  movement,  or  diastole,  is  accom- 
panied by  the  second  sound,  by  an  influx  of  blood  from  the  auricle,  by  a  retrac- 
tile motion  of  this  cavity  most  observable  at  its  sinus,  and  by  a  retrocession  of 
the  apex  of  the  heart  from  the  walls  of  the  chest.  Next  succeeds  the  interval 
of  repose,  during  which  the  ventricles  remain  at  rest,  in  a  state  of  fullness, 
though  not  of  distention,  through  the  whole  period  intervening  between  the 
second  and  the  first  sounds  ;  but  the  auricle  remains  at  rest  during  the  first  por- 
tion only  of  that  period,  the  remainder  being  occupied  by  its  next  contraction, 
v%  j th  which  recommences  the  series  of  actions  described. —  Tronsl. 


590  EXPLORATION  OF  THE  HEART. 

diaphragm  and  intercostal  muscles.  From  the  proportions  above 
stated  it  follows,  that  in  twenty-four  hours  the  ventricles  have 
twelve  and  the  auricles  eighteen  hours  of  quiescence.  In  persons 
whose  pulse  is  habitually  below  fifty,  the  repose  of  the  ventricles 
is  more  than  sixteen  hours  in  the  four-and-twenty.*  Even  the 
muscles  of  voluntary  motion  have  often  not  more  rest  than  this, 
in  persons  subject  to  bodily  labor ;  and  some  of  the  muscles 
which  keep  the  head  and  trunk  erect  have  even  less,  especially 
such  as  have  not  their  action  completely  interrupted  by  sleep.f 
The  preceding  calculation  is  equally  exact,  whether  we  suppose 
the  dilatation  of  the  heart  to  be  passive,  or  consider  it  as  I  am 
disposed  to  do,  with  Pechlin,  as  active :  on  the  latter  hypothesis, 
we  cannot  suppose  that  the  same  muscular  fibres  produce  both 
the  dilatation  and  contraction  of  the  cavities. 

The  isochronism  of  the  ventricular  contraction  and  the  arterial 

*  I  have  seen  two  individuals  in  whom  the  pulse,  for  several  successive  days, 
did  not  exceed  20  beats  in  a  minute,  and  one  in  whom  it  was  only  16.  This 
singular  sluggishness  in  the  circulation  did  not  exist  in  these  individuals  when 
they  arrived  in  Paris  from  the  country  to  consult  me  ;  but  the  physicians  who 
had  the  care  of  them  in  the  country  noted  it  with  perfect  accuracy.  One  of 
them,  about  fifty  years  of  age,  exhibited  certain  signs  which  led  me  to  suspect 
some  affection  of  the  cervical  portion  of  the  spinal  marrow.  The  other,  a 
female  of  about  the  same  age,  manifested  symptoms  of  an  affection  of  the  heart. 
She  experienced  continual  pain  in  this  organ,  which  at  times  shot  up  through  the 
walls  of  the  chest  to  the  left  arm.  She  had  dyspnoea  on  mounting  stairs,  or  in 
walking  quick,  and  yet  no  anormal  condition  of  the  heart  had  been  discovered 
either  by  auscultation  or  percussion.  On  examining  this  patient,  I  found,  ac- 
companying a  very  languid  state  of  the  circulation,  the  pulse  only  about  20  or 
30  in  a  minute.     Gentle  exercise,  instead  of  accelerating,  reduced  it  still  more. 

I  have  frequently  seen  the  pulse,  under  the  influence  of  digitalis,  fall  as  low 
as  40  in  a  minute,  and  once  from  the  same  cause,  so  low  as  28. 

A  case  is  cited  in  the  Gazette  des  Hopitaux  of  Oct.  9,  1834,  in  which  imme- 
diately following  the  administration  of  digitalis,  the  pulse  was  reduced  so  low 
as  17  pulsations  in  a  minute. 

In  making  observations  of  this  kind,  it  is  important  that  w.e  should  be  on  our 
guard  against  an  error  to  which  we  arc  obnoxious  in  certain  cases,  which  cases 
are  by  no  means  rare,  in  which  between  the  very  strong  and  full  pulsations, 
others  much  weaker  and  smaller  take  place,  which,  contrasting  so  feebly  with 
those  which  go  before  and  after,  might  escape  our  notice  and  lead  us  to  suppose 
that  the  pulse  was  much  slower  than  it  really  was.  It  is  necessary  therefore, 
that  we  should  be  apprised  of  the  possibilities  of  such  a  mistake. — Andral. 

t  It  ought  to  be  remarked,  on  the  other  hand,  that  the  muscles  subject  to  the 
influence  of  the  will,  as  those  of  the  limbs,  and  which  are  liable  to  great  tempo- 
rary increase  of  action,  enjoy  the  longest  repose.  Thus,  in  a  person  that  has 
walked  twelve  hours  out  of  the  twenty-four,  the  muscles  of  the  legs  and  thighs 
will  have,  in  reality,  only  acted  during  six,  inasmuch  as  the  extensors  and  flexors 
act  alternately  ;  but  the  muscles  of  the  trunk  will  have  been,  during  the  whole 
journey,  in  a  state  of  almost  continued  contraction,  although  in  a  much  less  de- 
gree and  in  some  sort  automatic.  From  this  it  may  be  concluded  that,  in  the  case 
of  a  person  in  health,  who  takes  a  degree  of  exercise  proportioned  to  his  strength, 
the  sum  of  action  is  nearly  equal  in  every  order  of  muscles,  including  the  heart. 
And  from  the  same  facts  we  may  deduce  this  further  conclusion,  which  is  more- 
over in  accordance  with  experience,  that  those  occupations  which,  like  that  of 
the  laborer,  lead  to  a  nearly  equal  exercise  of  the  different  parts  of  the  muscular 
system,  are  the  most  conducive  to  health. — Author. 


OF    THE    RYTHM. 


591 


pulse,  is  best  perceived  when  the  pulse  is  slow.*  Indeed,  when 
the  pulse,  is  at  all  more  frequent  than  natural,  (say  about  72,)  it 
is  not  easy  to  diminish  this  isochronism.  In  this  case,  also,  the 
interval  of  repose  after  the  contraction  of  the  auricles,  is  not  dis- 
tinguishable ;  the  period  of  the  contraction  of  the  ventricles,  but 
not  of  the  auricles,  is  shortened  ;  while  there  is  commonly  diminu- 
tion of  the  impulse,  but  increase  of  the  sound,  attending  the  sys- 
tole of  the  ventricles.  It  results  from  these  observations  and 
others  in  a  preceding  page,  that  when  the  contraction  of  the  ven- 
tricles becomes  slower  than  usual,  this  prolongation  of  their  action, 
is,  in  general,  taken  neither  from  the  period  of  the  auricular  con- 
traction nor  from  the  period  of  repose,  but  is  a  direct  addition  to 
the  time  occupied  by  the  contractions  of  the  heart :  hence  the 
pulse  becomes  always  slower  in  such  cases. 

Hypertrophy  of  the  ventricles,  when  in  a  moderate  degree, 
presents,  in  some  respects,  an  exaggeration  of  the  natural  rythm 
of  the  heart's  actions.  The  contraction  of  the  ventricles  becomes 
less  noisy,  and  more  readily  distinguishable  from  that  of  the 
auricles.  After  the  latter,  the  interval  of  quiescence  is  well 
marked,  and  contracts  very  sensibly  with  the  sound  that  precedes, 
and  the  motion  which  follows  it.  But  in  hypertrophy  carried  to 
a  very  high  degree,  the  rythm  of  the  heart  is  singularly  changed. 
In  this  case,  the  contraction  of  the  ventricles  is  greatly  prolonged. 
This  at  first  is  perceived  as  a  profound  and  obscure  motion,  which 
gradually  augments,  elevates  the  applied  ear,  and  then  termi- 
nates in  producing  the  impulse  or  shock.  This  contraction  is 
unaccompanied  by  any  sound,  or,  if  this  exists,  it  is  merely  a 
sort  of  murmur  like  that  of  respiration.  The  contraction  of  the 
auricles  is  extremely  short,  and  almost,  or  altogether,  without 
sound :  and  in  some  cases  the  systole  of  the  ventricles  seems 
scarcely  over  before  they  begin  to  swell  afresh.  The  interval  of 
repose  no  longer  exists,  or  is  confounded  with  the  almost  imper- 
ceptible commencement  of  the  contraction  of  the  ventricles.  In 
extreme  cases,  there  is  no  sound  distinguishable  but  the  murmur 
above  mentioned,  and  we  merely  recognize  an  elevation  of  the 
heart  corresponding  to  each  beat  of  the  pulse. 

In  these  cases  the  increased  brevity  of  the  auricular  contrac- 
tion, or  its  apparent  absence,  is  not  the  consequence  of  their  di- 
minished contractibility  merely,  but,  also,  of  their  contraction 
commencing  before  that  of  the  ventricles  has  entirely  ceased. 
This  becomes  particularly  evident  in  certain  cases  in  which  the 

• 

*  The  isochronism  of  the-  ventricular  systole  and  the  arterial  pulse,  only  exists 
in  vessels  near  the  heart  :  in  the  arteries  of  the  extremities  the  heat  of  the  pulse 
succeeds  the  beat  of  the  heart  after  a  well-marked  interval ;  and  the  length  of 
this  interval  progressively  decreases  in  the  vessels  as  we  approach  the  heart, 
showing  that  the  impulse  communicated  to  the  column  of  blood  in  the  arterial 
tree  is  strictly  progressive. —  Trund. 


592  EXPLORATION  OP  THE  HEART. 

auricles  are  found  to  contract  very  forcibly  and  in  a  convulsive 
manner,  with  a  loud  sound,  apparently  anticipating  the  contrac- 
tion of  the  ventricles  and  interrupting  it  in  its  mid-course.  This 
kind  of  anticipation,  which  is  frequently  observed  in  the  case  of 
palpitation,  produces  an  effect  very  difficult  to  be  described, 
though  easily  recognized  when  it  has  been  once  heard  :  it  is  a 
sort  of  subsultus  like  what  would  be  produced  by  a  spring  placed 
under  the  heart,  which,  on  being  let  go,  should  suddenly  strike 
this  organ,  and  stop  its  motion.  It  seems,  in  short,  as  if  the 
movement  in  question  did  not  proceed  from  the  heart  itself,  but 
from  a  contractile  organ,  of  greater  power,  placed  beneath  it. 
This  convulsive  contraction  is  sometimes  double,  that  is,  we  per- 
ceive two  successive  contractions  without  any  interval ;  but  im- 
mediately after,  the  heart  regains  its  usual  rythm. 

When  the  walls  of  the  left  ventricle  are  naturally  thin,  or  have 
become  so  from  dilatation,  even  in  a  slight  degree,  the  rythm  of 
the  heart's  actions  is  quite  different.  In  this  case,  the  interval 
of  repose  after  the  contraction  of  the  auricle  is  no  longei  per- 
ceptible. The  contraction  of  the  ventricles  is  more  sonorous, 
more  resembling  that  of  the  auricles,  and  more  approaching  the 
latter  in  duration.  From  these  circumstances  it  necessarily  fol- 
lows that,  in  such  subjects,  the  pulse  must  be  habitually  frequent, 
and  the  synchronism  of  the  systole  of  the  ventricles  and  the 
diastole  of  the  arteries,  of  more  difficult  recognition.  Such  per- 
sons are,  therefore,  very  unfit  subjects  on  which  to  study  the 
mechanism  of  the  heart's  actions  ;  and  ought  not  to  be  explored 
by  the  young  auscultator,  until  after  he  has  acquired  the  know- 
ledge of  the  natural  rythm  on  individuals  more  favorably  consti- 
tuted. 

To  the  phenomena  enumerated  are  conjoined,  as  already  men- 
tioned, a  lesser  impulse,  and  a  more  extensive  range  of  the  sound 
of  the  heart's  pulsation.  Together,  these  signs  uniformly  indi- 
cate a  heart  disposed  to  dilatation, — that  is  to  say,  (to  assume  a 
standard  of  comparison  in  a  case  where  there  cannot  be  a  fixed 
standard)  a  heart  in  which  the  walls  of  the  left  ventricles  have, 
at  most,  a  thickness  double  that  of  the  right.  This  condition  of 
the  organ  of  circulation  is  congenial  in  many  cases.  It  does  not 
necessarily  abridge  life,  but  is  usually  conjoined  with  a  delicate 
constitution,  a  small  stature  and  puny  muscles.  Persons  so  con- 
stituted are  narrow  chested,  and  have  the  respiration  habitually 
short.  In  the  case  of  fever  and  disease  of  the  organs  of  respira- 
'  tion,  they  experience,  ceteris  paribus,  a  greater  dyspnoea  than 
other  persons.  Should  the  condition  in  question  increase  only  in 
a  slight  degree,  a  dilatation  of  the  heart  is  the  necessary  conse- 
quence. 

When   dilatation   actually    exists,  it  produces  merely  an    in- 


OF    THE    RYTHM. 


>93 


crease  of  all  the  characters  which  indicate  a  heart  with  thin  pa- 
rietes.  The  contraction  of  the  ventricles  becomes  as  short  and 
noisy  as  that  of  the  auricles ;  the  pulse,  consequently,  becomes 
very  frequent :  and  the  isochronism  of  the  arterial  pulse  and  the 
contraction  of  the  ventricles  become  quite  undistinguishable.  It 
even  sometimes  appears,  by  the  reverse  of  the  natural  order,  as 
if  the  arterial  pulse  coincided  with  the  contraction  of  the  auri- 
cles. This  result  frequently  depends  on  a  mere  illusion  of  hear- 
ing, occasioned  by  the  frequency  of  the  heart's  contractions ; 
but  there  certainly  are  some  subjects,  in  whom,  even  in  the  state 
of  health,  the  contraction  of  the  ventricles  and  the  beat  of  the 
pulse  do  not  perfectly  accord, — the  diastole  of  the  artery  being 
always  a  little  later.  To  these  signs  we  must  add — the  absence 
of  any  sensible  impulse ;  the  extension  of  the  heart's  pulsation 
over  the  whole  or  greater  part  of  the  chest ;  and  sometimes  the 
existence  of  this  in  as  great  force  under  the  clavicles  and  the 
axilla  as  in  the  region  of  the  heart  itself.  This  last  character,  in 
particular,  may  be  regarded  as  pathognomonic,  if  the  patient  is 
not  phthisical  and  pectoriloquous  in  the  places  mentioned  ;  and, 
like  all  the  others  mentioned,  it  is  more  marked  in  proportion  as 
the  dilatation  is  more  extensive. 

Such  are  the  phenomena  presented  by  the  regular  rythm  of 
the  heart,  as  well  in  a  sound  state  of  the  organ,  as  when  its  walls 
are  either  thicker  or  thinner  than  natural.*  But  in  many  circum- 
stances, which  do  not  at  all  amount  to  disease  or  even  serious  in- 
disposition, this  rythm  exhibits  various  anomalies.  These  are 
commonly  classed  under  three  principal  heads — palpitations, 
irregularities,  and  intermissions ;  and  I  shall  notice  them,  in 
order,  after  having  given  an  account  of  certain  anomalies  in  the 
sound  of  the  heart. — In  ihe  whole  of  the  present  chapter  I  have 
supposed  the  heart  to  be  either  quite  sound,  or  affected  similarly 
and  equally  in  both  sides ;  but  when  only  one  of  the  sides  of  the 
heart  is  affected,  and  more  particularly  in  the  case  of  contraction 

*  I  have  cited  in  my  Clinique  Medicale  a  case  in  which  at  each  contraction  of 
the  heart,  more  than  two  sounds  were  observed  to  occur.  M.  Bouillaud,  in  his 
work,  also  mentions  analogous  cases,  which  for  the  details  accompanying  them, 
are  of  great  importance.  These  are  instances  of  a  remarkable  aberration  in 
the  rythm  of  the  heart.  Such  anomalies,  according  to  M.  Bouillaud,  are  never 
observed  to  take  place,  except  in  individuals  who  presented  after  death,  con- 
tractions of  one  or  more  of  the  orifices  of  the  heart,  valvular  indurations,  and 
very  frequently  traces  of  a  more  or  less  recent  pericarditis. 

Not  unfrequently,  instead  of  two  sounds,  three  and  sometimes  four,  are  dis- 
tinguished. In  one  case  which  has  already  been  reported,  the  first  sound  seemed 
to  be  a  combination  of  the  natural  claquement  and  a  slight  bellows  sound  :  to  this 
immediately  succeeds  two  other  sounds  which  were  accompanied  by  a  dry  crack- 
ling noise,  following  which  was  heard  the  fourth  and  last  sound  being  a  very 
pure  bellows  sound. 

In  another  patient,  for  many  successive  days  three  sounds  were  heard,  and. 
for  several  days  following  four  sounds  were  distinguished. — Jlndral. 

75 


594  EXPLORATION  OF  THE  HEART. 

of  the  orifices,  the  rythm,  the  sound,  and  the  impulse  of  the  sides, 
may  differ  so  much  as  to  occasion  results  that  might  be  attributed 
to  two  different  hearts. 

As  in  the  preceding  discussion  I  have  constantly  used  the  ex- 
pression of  contraction  of  the  auricles,  I  think  it  necessary  to 
remark  that  I  clo  not  by  this  intend  to  prejudge  the  question 
lately  agitated  by  my  friend,  Dr.  Barry,  a  distinguished  physician 
of  the  English  army.  This  gentleman  has  endeavored  to  prove, 
by  direct  experiment,  that  atmospheric  pressure  is  the  chief  cause 
of  the  circulation  in  the  veins.*  He  remarks,  in  the  first  place, 
that  the  dilatation  of  the  chest  in  inspiration,  produces  a  tendency 
to  a  vacuum  in  the  whole  thoracic  cavity  ;  that  the  walls  of  the 
pericardium  and  heart  follow  the  motion  of  the  chest ;  that,  con- 
sequently, at  the  very  time  the  air  rushes  into  the  bronchi,  the 
blood  is  rapidly  sucked  up  by  the  right  auricle,  and  is  precipi- 
tated into  the  left  auricle,  as  well  from  the  same  cause  as  from 
the  pressure  exerted  on  the  pulmonary  vessels.  The  chief  expe- 
riments on  which  Dr.  Barry  founds  his  doctrines,  are  the  fol- 
lowing:  1.  if  we  introduce  into  the  internal  jugular  vein  of  a 
horse,  a  bent  glass  tube,  and  place  the  other  extremity  of  it  in  a 
vessel  containing  a  colored  fluid,  we  find  this  drawn  into  the 
vein  at  each  inspiration,  until  it  is  all  exhausted ;  2.  the  same 
experiment  made  by  adapting  the  glass  tube  to  a  metallic  one  in- 
troduced into  the  pericardium  gives  precisely  the  same  results ; 
3.  having  laid  open  the  abdomen  of  a  horse,  and  separated  the 
vena  cava,  if  we  lay  hold  of  the  latters  we  find  the  vein  become 
emptier  and  flaccid  during  each  inspiration.  Having  myself 
witnessed  several  of  Dr.  Barry's  experiments,  1  am  convinced  of 
the  correctness  of  his  opinion  respecting  the  influence  of  atmos- 
pheric pressure  on  the  circulation  in  the  veins ;  and  I  consider  his 
discovery  as  the  most  remarkable  addition  that  has  been  made  to 
that  of  his  illustrious  countryman,  Harvey.  Wherefore,  if  we 
admit,  as  I  think  we  must,  the  truth  of  Dr.  Barry's  proposition, 
we  must  at  the  same  time  admit,  with  him,  that  the  auricles  are 
merely  reservoirs,  which  are  constantly  full,  and  on  which  the 
ventricles  draw  at  each  diastole ;  so  that  what  I  have  termed  con- 
traction of  the  auricles,  must  be  understood  only  of  their  sinuses 
or  appendixes.  If  this  were  not  the  case,  and  the  auricle  con- 
tracted completely,  inspiration  ought  continually  to  derange  the 
regularity  of  the  heart's  action, — which  is  not  the  fact.  I  agree 
with  Dr.  B.  that  the  auricles  habitually  contain  much  more  blood 

*  Recherches  experimentales  sur  la  cause  du  mouveinent  du  sang,  &c.  par 
David  Barry,  M.D.  &c.  Paris,  1825.— Dr.  Barry  has  since  published  his  work  in 
English  under  the  title  of  "  Experimental  Researches  on  the  Influence  exer- 
cised by  Atmospheric  Pressure,  &c.  Lond.  1826.  This  work  is  highly  de- 
serving the  attention  of  physiologists  and  practitioners.—  Trmsl. 


OF    THE    RYTHM. 


595 


than  the  ventricles  draw  off  at  each  diastole,  and  that  the  sinus 
contracts  with  much  greater  force  than  the  auricle  itself ;  at  the 
same  time,  I  by  no  means  consider  the  latter  as  entirely  passive  ; 
on  the  contrary,  I  think  it  is  proved  by  the  inspection  of  the 
heart  in  a  living  animal,  that  the  whole  of  the  auricle  does  con- 
tract, but  that  the  contraction  is  much  stronger  and  more  evident 
in  the  sinus.  If  inspiration  does  not  occasion  any  habitual  alter- 
ation in  the  rythm  of  the  heart's  actions,  this  arises,  no  doubt,  on 
account  of  the  eminently  elastic  and  extensile  texture  of  the  au- 
ricle, whereby  it  is  enabled  still  to  be  in  a  state  of  considerable 
distention  at  the  very  time  at  which  the  contractile  movement 
takes  place,  if  its  contraction  coincides  with  the  motion  of  inspi- 
ration.— If  we  compare  the  experiments  of  Dr.  Barry  with  the 
observations  of  Pechlin  on  the  active  dilatation  of  the  heart  of 
vigorous  animals,  at  the  moment  of  separation  from  the  body, 
(which  he  states  to  be  sufficient  to  press  open  the  compressing 
hand)  the  mechanism  of  the  circulation  in  the  veins  seems  easily 
understood.  The  blood  flows  copiously  into  the  auricles  at  each 
inspiration,  and  the  ventricles  draw  on  these  reservoirs  at  each 
diastole  :  the  contraction  of  the  auricles  is  a  necessary  consequence 
of  the  dilatation  of  the  ventricle  :  it  is  contemporaneous  with  the 
ventricular  diastole,  and  is  requisite  to  prevent  a  vacuum.  Many 
phenomena,  as  Dr.  Barry  observes,  are  explained  by  the  mecha- 
nism just  described,  and,  among  others,  the  descent  of  the  brain 
during  inspiration,  and  its  rise,  or  rather  dilatation,  during  expi- 
ration ;  the  reflux  of  blood  into  the  jugular  veins  from  coughing 
or  a  prolonged  expiration ;  and  the  sudden  death  occasioned  by 
the  introduction  of  air  into  the  internal  jugular  vein,  a  case  which 
has  occurred  two  or  three  times  within  these  few  years,  during 
surgical  operations.* 

*  In  attempting  to  lay  before  the  reader  the  various  opinions  promulgated  by- 
numerous  writers  on  the  subject  of  the  motions  and  sounds  of  the  heart,  I  gladly 
avail  myself  of  my  friend  Dr.  Williams's  permission  to  introduce  the  chief  part 
of  the  condensed  and  accurate  outline  of  the  subject  given  in  tlie  appendix  to  the 
second  edition  of  his  excellent  work  on  Auscultation,  entitled  Ji  Rational  Expo- 
sition of  the  Physical  Signs  of  the  Diseases  of  the  Lungs,  fyc.  Lond.  1833.  And 
while  I  accord  with  him  as  to  the  inadequacy  of  any  one  of  the  numerous  theo- 
ries fully  to  explain  the  phenomena,  he  will,  I  know,  forgive  me  for  classing  his 
own  explanation  of  the  causes  of  the  sounds  in  the  same  category.  It  is  fort- 
unate, in  a  practical  point  of  view,  that,  whatever  be  the  rationale  of  the  phe- 
nomena, the  facts,  now  I  think  established,  of  the  first  sound  being  coincident 
with  the  systole,  and  the  second  sound  with  the  diastole  of  the  ventricles,  suffices 
for  our  guidance,  in  regard  to  diagnosis,  in  the  great  majority  of  cases.  I  now 
transcribe  Dr.  Williams's  critical  outline  : 

On  the  Motions  and  Sounds  of  the  Heart. — It  is  of  considerable  utility  in  the 
examination  of  a  controverted  point,  to  review  fairly  the  various  opinions  res- 
pecting it,  and  by  collating  them  with  available  facts,  to  determine  the  compar- 
ative probability  of  these  views  :  if  this  had  been  done  with  regard  to  the  present 
subject,  much  useless  speculation  might  have  been  saved,  and  some  animal  life 
spared  ;  for  any  attentive  reader  of  the  periodical  medical  literature,  must  have 
perceived  that  the  same   opinions  have  been   broached,  refuted,  and  revived  by 


596  EXPLORATION    OF    THE    HEART. 

successive  writers,  and  the  same  experiments  performed  and  reiterated  in  appar- 
ent ignorance  of  preceding  inquiries. 

On  this  account,  I  am  induced  to  give  a  summary  sketch  of  the  leading  features 
in  the  views  which  have  been  advanced  respecting  the  motions  and  sounds  of 
the  heart,  and  bring  them  successively  to  the  test  of  some  well-established  path- 
ological or  physiological  facts.  Others,  besides  the  names  quoted,  may  have 
supported  the  views  in  question,  but  it  is  only  the  views  which  I  wish  to  deal 
with,  and  I  cite  the  writers  with  a  wish  to  show  that  the  arguments  which  each 
has  advanced  have  been  carefully  studied. 

1.  M.  Laennec.  a.  1st  sound,  impulse,  and  pulse,  caused  by  the  ventricular 
systole,  b.  2nd  sound  by  the  systole  of  the  auricles. — Remarks,  a.  Generally 
admitted,  and  proved  by  various  facts  and  experiments,  b.  Disproved  by  the 
fact  noticed  by  Harvey  and  Haller,  and  confirmed  by  modern  experiments,  that 
the  auricular  contraction  immediately  precedes  that  of  the  ventricles  ;  also  by 
this  fact,  that  both  sounds  sometimes  continue  after  the  auricles  have  ceased  to 
contract.  (Dr.  Hope's  Experiments  on  Asses.  See  his  work,  p.  36  )  [And  yet 
more  completely  disproved  by  the  fact,  that  for  the  production  of  the  two  sounds 
the  division  of  the  heart  into  auricle  and  ventricle  is  not  necessary.  See  Dr. 
Stokes's  paper  on  Aneurism  in  the  Dublin  Journal.     J.  F.] 

2.  Mr.  Turner.  (Med.  Chir.  Trans.  Edin.  vol.  iii.)  2d  sound  produced  by  the 
falling  back  of  the  heart  on  the  pericardium  after  the  systole  of  the  ventricles. — 
Remark.  Disproved  by  the  fact,  that  the  sound  continues  when  the  heart  pul- 
sates out  of  the  pericardium. 

3.  Dr.  Corrigan.  (Trans,  of  King's  and  Queen's  Coll.  of  Phys.  Ireland.)  a. 
Impulse  and  1st  sound  caused  by  the  rush  of  blood  into  the  ventricles  during  the 
auricular  systole,  b.  2nd  sound  by  the  ventricular  systole,  which  he  considers 
to  be  instantaneous. — Remarks,  a.  Disproved  by  the  clearly  ascertained  facts, 
that  the  1st  sound  and  impulse  accompany  the  systole  of  the  ventricles  when  the 
auricles  have  ceased  to  contract,  b.  Disproved  clearly  in  large  animals  by  the 
ventricular  systole,  (which  is  not  instantaneous.)  and  the  pulse  of  arteries  near 
the  heart,  evidently  preceding  the  2nd  sound  ;  (Dr.  Hope's  Experiments,  p.  31, 
of  his  work;  and  those  of  Mr.  Carlile,  Dublin  Journal  of  Mcdir.  Sci.  vol.  iv.) 
and  further  disproved  by  several  pathological  phenomena. 

4.  Dr.  David  Williams.  (Edin.  Med.  &  Surg.  Journ.  Oct.  1829.)  2nd  sound 
caused  by  the  flapping  open  of  the  auriculo-ventricular  valves  against  the  sides 
of  the  ventricles;  these  valves  he  supposes  to  be  opened  by  the  musculi  papilla- 
res. — Remark.  This  is  contrary  to  the  received  opinion  of  anatomists  with  res- 
pect to  the  functions  of  the  auricular  valves  and  musculi  papillares,  and  there  is 
no  collateral  argument  to  maintain  so  gratuitous  an  assumption. 

5.  M.  Pigeaux.     (Arch.  Generales  de  Medecine,  Juillet  et  Novembre,  1832.) 

a.  1st  sound  produced  by  the  blood  rushing  into  the  ventricles  at  the  moment  of 
their  diastole,  b.  2nd  sound  by  the  collision  of  the  blood  against  the  walls  of 
the  aorta  and  pulmonary  artery,  c.  The  ventricles  contract  in  a  moment  of 
silence  before  the  2nd  sound,  d.  The  intensity  of  the  sounds  proportioned  to 
the  force  by  which  the  blood  is  impelled. — Remarks,  a.  Opposed  by  the  facts 
stated  against  3a;  opposed  also  by  many  pathological  facts,  such  as  the  occur- 
rence of  a  murmur  with  the  1st  sound   in  case  of  diseased  semi-lunar   valves. 

b.  Disproved  by  the  fact  that  the  2nd  sound  occurs  distinctly  after  the  pulse  in 
the  carotids,  and  therefore  after  that  in  the  larger  arteries,  c.  Opposed  by  the 
observation,  that  the  1st  sound  and  ventricular  systole  occur  together  and  cor- 
respond in  duration,  d.  This  is  opposed  by  the  morbid  phenomena  of  dilatation 
of  the  ventricles,  which  always  increases  the  first  sound,  and  of  hypertrophy, 
which  diminishes  both  sounds. 

6.  M.  Majendie.  (In  a  Lecture  read  at  the  College  of  France,  quoted  by  M. 
Pigeaux.)  1st  sound  and  impulse  produced  by  the  ventricular  diastole  impelling 
the  apex  ;  the  2nd  sound  by  the  systole  impelling  the  base  of  the  heart  against 
the  walls  of  the  chest.     Remark.     Disproved  by  the  fact  opposed  to  2. 

7.  M.  Rouanet.  (Journ.  Hebdom,  No.  97 ;  also  Mr.  Bryan,  Lancet,  Sept. 
1833.)  a.  1st  sound  caused  by  the  closing  of  the  mitral  and  the  tricuspid  valves 
against  the  auriculo-ventricular  orifices  during  the  ventricular  systole,  b.  2nd 
sound  by  the  reaction  of  the  blood  in  the  arteries  on  the  semi-lunar  valves  at 
the  moment  of  the  ventricular  diastole. 

8.  Mr.  H.  Carlile.     (Dublin  Journal  of  Medical  Science,  vol.  iv.     The  essay 


ON   THE    MOTIONS    AND    SOUNDS    OF    THE    HEART.  597 

was  likewise  read  at  the  Cambridge  Meeting  of  the  British  Association.) 
«.  1st  sound  produced  by  the  rush  of  blood  into  the  arteries  during  the  ven- 
tricular systole,  b.  2nd  sound  by  the  reaction  of  the  semi-lunar  valves  as  stated 
in  b.  7. 

9.  Dr.  Hope,  a.  1st  sound  and  impulse,  caused  by  the  ventricular  systole  ;  b. 
2nd  sound  and  back  stroke,  or  second  impulse,  by  the  ventricular  diastole.  The 
natural  as  well  as  morbid  sounds  produced  by  the  motions  of  the  contained  fluid. 
Before  we  sift  the  questionable  points  in  these  three  last  views,  it  will  be 
proper  to  review  the  principal  grounds  on  which  we  adopt  their  description  of 
the  sounds  and  motions,  in  defiance  of  many  preceding  authorities.  Having 
been  present  at  some  of  Dr.  Hope's  experiments  en  the  ass,  I  bad  ample  oppor- 
tunity of  convincing  myself  that  the  sounds  were  connected  with  the  motions 
of  the  ventricles  only.  When  the  pericardium  was  laid  open,  and  the  large 
heart  exposed,  vigorously  pulsating;  the  eye  watching  it,  the  hand  grasping  it, 
and  the  stethoscope  applied  to  it,  gave  perfectly  corresponding  impressions,  in- 
somuch that  on  substituting  touch  for  hearing,  it  was  difficult  to  banish  the  im- 
pression that  one  still  heard  the  double  sound  which  was  so  exactly  represented 
in  quality  and  duration  by  the  motions  of  the  ventricles,  as  felt  and  seen;  and 
on  combining  touch  and  hearing,  by  applying  the  hand  and  the  stethoscope  at 
the  same  time,  these  impressions,  which  corresponded  in  nature  and  duration, 
were  found  also  to  be  perfectly  simultaneous.  The  apex  of  the  heart  was  ob- 
served and  felt  to  strike  against  the  ribs  at  each  systole,  and  thus  was  explained 
the  impulse.  The  motions  of  the  auricles,  when  regular,  preceded  the  ventri- 
cular motions  and  sounds;  they  were  slight  and  undulatory,  increasing  from  the 
sinus  to  the  appendix,  where  they  terminated  suddenly,  and  were  immediately 
followed  by  the  ventricular  systole.  They  afterwards  became  irregular,  some- 
times failing  and  sometimes  occurring  twice  slightly  during  the  period  of  ven- 
tricular repose,  and  in  one  experiment  entirely  ceased  some  minutes  before  the 
movements  and  sounds  of  the  ventricles.  In  no  instance  were  they  attended 
with  any  perceptible  sound.  This  account  is  confirmed  by  the  experiments  of 
Mr.  Carlile,  which  satisfactorily  explain  the  succession  of  the  motions  of  the 
auricles  and  ventricles  ;  but  they  were  performed  on  animals  too  small  to  illus- 
trate the  sounds.  He  very  justly  shows  that  the  pulse  cannot  be  simultaneous 
in  all  the  arteries  at  once,  but  must  be  successive,  transmitted  in  a  wave  from 
the  heart  to  the  end  of  these  elastic  tubes. 

Although  it  seems  fairly  established  that  the  first,  or  dull  sound,  is  produced 
by  the  systole  of  the  ventricles;  and  the  second,  or  quick  one,  by  their  diastole, 
it  is  by  no  means  clearly  explained  in  what  way  these  actions  generate  these 
sounds.  The  following  causes  have  been  severally  assigned  as  physically  ca- 
pable of  generating  the  first  sounds  during  the  systole  of  the  ventricles. 
1.  The  collision  of  the  particles  of  fluid  in  the  ventricles.  (Dr.  Hope.) — 2.  The 
rush  of  blood  into  the  great  arteries.  (Mr.  Carlile.)— 3.  The  closing  of  the 
mitral  and  tricuspid  valves.  (M.  Rouanet,  Mr.  Bryan.) — 4.  The  muscular^con- 
traction  itself. 

1.  The  first  of  these  explanations  is  ingeniously  proposed  by  Dr.  Hope,  but 
he  advances  no  facts  in  direct  proof  of  the  hypothesis.  In  a  number  of  experi- 
ments which  I  have  made  on  the  generation  of  sound,  I  have  found  liquids,  of 
all  bodies,  the  most  difficult  to  excite  to  sonorous  vibration  ;  and  although  they 
readily  transmit  vibrations  already  produced  in  solids,  it  requires  a  combination 
of  circumstances  to  make  them  originate  sound.  This  is  consistent  with  the 
explanation  given  of  the  production  of  sound  ;  for  impulses  which  throw  solids 
into  sonorous  vibration,  are  expended  in  liquids  in  causing  a  displacement  of 
their  particles.  On  making  an  experiment  with  a  gum  elastic  bottle,  by  filling 
it  with  water,  and  then  forcibly  compressing  it  under  water  by  the  end  of  the 
stethoscope,  (avoiding  the  use  of  the  hand,  for  that  produces  its  own  muscular 
sound,)  I  have  failed  in  procuring  any  sound  at  all  approaching  to  that  of  the 
heart's  contraction.  The  blood  yields  readily  to  the  contracting  ventricle,  and 
there  being  no  obstacle  to  the  escape  of  blood  from  it,  further  than  the  weight 
of  the  arterial  column,  which  the  normal  action  of  the  heart  can  quietly  and 
steadily  overcome,  it  passes  into  the  arteries  without  vibration.  But  if  there 
be  an  obstacle  to  the  current  of  the  blood  from  the  ventricle,  whether  that  ob- 
stacle be  a  narrowing  or  a  projection  in  the  orifice,  the  current  will  act  on  it  just 
as  the  bow  docs  on  the  string  of  a  violin;  a  sound  will  be  excited,  and  thus  are 


59S  EXPLORATION  OF  THE  HEART. 

produced  valvular  murmurs.  Again,  if  instead  of  the  orifices  being  narrowed, 
the  heart  contracts  with  unnatural  briskness,  expelling  its  contents  with  convul- 
sive energy,  the  natural  outlets  then  become  relatively  narrow,  and  are  thrown 
into  vibrations  :  this  is  the  rationale  of  the  bellows  murmur  which  accompanies 
the  jerking  pulse  of  pericarditis  and  the  irritation  of  inanition.  But  the  dif- 
ference of  these  sounds,  and  of  the  circumstances  that  excite  them,  from  those 
of  the  normal  action  of  the  heart,  makes  me  hesitate  to  refer  the  latter  to  tin- 
same  principle ;  and  the  fact  that  the  morbid  are  often  superadded  to  the  natural 
sounds,  also  inclines  me  to  think  that  they  have  a  distinct  cause. 

2.  The  second  explanation  of  the  first  sound,  tthe  rush  of  blood  into  the  lar- 
ger arteries,  is  perhaps  less  liable  to  the  acoustic  objection  before  urged  than  the 
preceding  opinion,  lor  the  blood  has  acquired  an  impulse  when  it  enters  the  ar- 
teries, and  if  its  course  there  is  not  free,  it  might  readily  produce  a  sound.  But 
in  their  natural  state,  the  arteries  give  passage  to  the  blood  as  smoothly  as  the 
heart  parts  with  it,  and  it  would  prove  an  imperfection  in  nature  were  it  other- 
wise. Moreover,  if  the  explanation  were  true,  the  large  arteries  rather  than 
the  heart  would  be  the  principal  seat  of  the  sound  ;  and  the  sound  should  be 
increased  by  an  hypertrophied  heart  with  a  strong  pulse,  and  diminished  by  a 
dilated  heart,  and  a  weak  pulse,  yet  the  reverse  of  these  is  presented  in  nature. 

3.  The  closing  of  the  auricular  valves.  The  principal  objection  to  this  as  the 
only  cause  of  the  first  sound,  is,  that  it  must  be  instantaneous,  and  confined  to 
the  first  part  of  the  ventricular  systole,  whereas  we  know  that  the  first  sound  is 
prolonged  during  the  whole  period  of  this  action. 

4.  Although  Laennec  referred  the  first  sound  to  the  systole  of  the  ventricles, 
he  did  not  attempt  to  define  the  physical  cause  of  its  production.  I  have  ven- 
tured to  class  it  among  the  muscular  sounds  which  Dr.  Wollaston  first  noticed 
to  occur  in  all  cases  of  rapid  muscular  contraction.  This  sound  may  be  exem- 
plified by  applying  the  fleshy  part  of  the  thumb  to  the  stethoscope  or  naked  ear, 
and  bending  and  straightening  the  thumb.  It  is  louder  in  muscles  that  are  thin, 
and  in  a  state  of  considerable  tension  ;  and  it  is  remarkable  that  it  does  not 
cease  with  the  apparent  movement,  but  continues  as  long  as  the  muscle  remains 
contracted  and  tense  :  it  then  takes  on  an  intermitting  character  like  the  noise 
of  the  rolling  of  a  carriage  over  rough  pavement,  whence  Dr.  Wollaston  was 
led  to  infer  that  muscular  action  is  not  perfectly  continued,  but  consists  of  a  se- 
ries of  minute  contractions  and  relaxations.  A  good  example  of  it  may  be  ob- 
tained on  applying  the  stethoscope  to  the  neck  of  a  person  who  holds  his  head 
back  towards  the  opposite  side,  and  then  throws  the  platysma  myoides  into  con- 
traction. It  still  appears  to  me,  that  the  most  simple  and  satisfactory  way  of 
accounting  for  the  first  or  systolic  sound  of  the  heart,  is  to  refer  it  to  this  class 
of  sounds.  Their  physical  production  seems  to  depend  on  the  tension  into 
which  the  fibres  of  muscles  are  thrown  when  they  contract ;  and  the  self-acting 
power  of  these  fibres  constitutes  them  the  motors  as  well  as  the  subjects  of  so- 
norous vibrations.  Here  we  have  to  remark  the  extreme  facility  with  which 
the  motions  of  solids  produce  sounds,  compared  with  those  of  fluids  :  for  it  is 
almost  impossible  to  touch,  stretch,  bend,  or  compress  solids,  without  throwing 
them  into  sonorous  vibrations.  The  varieties  observed  in  the  contraction  of  the 
heart  seem  to  me  to  be  perfectly  explicable  on  this  principle.  The  sound  be- 
gins the  moment  the  fibres  arrive  at  a  state  of  tension  ;  it  continues  until  the 
contraction  is  completed  and  the  blood  expelled  from  the  ventricle,  and  ceases 
the  instant  of  the  diastole.  M.  Pigeaux  is  in  error  when  he  maintains  that  mus- 
cular sounds  cannot  be  produced  under  water  :  I  find  them  more  distinct  and 
free  from  adventitious  sounds  of  the  surface,  and  I  have  been  able  to  imitate 
the  sounds  of  the  heart  very  exactly  by  muscular  movements  of  the  hand  under 
water. 

We  now  come  to  the  subject  of  the  second  sound,  which,  although  certainly 
occurring  at  the  moment  of  the  diastole  of  the  ventricles,  lias  received  several 
different  explanations  as  to  its  physical  cause.  The  only  two  which  appear  ten- 
able in  the  present  state  of  our  knowledge  are— 1.  the  reaction  of  the  arterial 
columns  of  blood  against  the  semi-lunar  valves.  2.  The  impulse  of  the  blooc 
from  the  auricles  refilling  the  ventricle  at  its  diastole. 

1.  The  first  of  these  bears  a  very  inviting  aspect;  for  the  second  sound  is  just 
of  that  abrupt  flapping  character  that  might  be  supposed  to  result  from  the  action 
of  a  thin  valve.     But  it  may  be  objected  to  this  view,  that  the  arteries,  more 


ON   THE    MOTIONS    AND    SOUNDS    OF    THE    HEART.  599 

than  the  heart,  should  be  the  seat  of  this  sound.  The  tense  column  which 
throws  these  valves  into  play,  should  receive  their  shock  more  forcibly  than  the 
heart,  which  at  that  moment  has  become  flaccid,  and  ill  adapted  to  transmit 
sound  or  impulse  (backstroke)  through  the  whole  of  its  substance.  There  are 
some  oases  of  disease  which  seem  also  to  militate  against  it.  In  a  case  described 
by  Dr.  Hope,  the  second  sound  on  the  left  side  was  quite  distinct,  yet  the  aortic 
valves  were  found  in  a  state  of  complete  rigidity.  (Case  20.)  In  another  case, 
the  second  sound  was  remarkably  loud  on  the  leftside,  with  a  weak  pulse  ;  yet, 
after  death  there  was  found  disease  of  the  mitral  valve  permitting  free  regurgita- 
tion, and  contraction  of  the  aorta:  this  combination  of  disease  must  have  dimin- 
ished the  action  of  the  aortic  valves.  (Case  15.)  The  action  of  these  valves 
will  be  strong,  in  proportion  as  the  arteries  are  well  filled,  and  the  pulse  strong, 
and  the  second  sound  should  in  this  view  be  proportionally  loud.  On  consult- 
ing the  records  of  some  cases  of  this  description,  I  have  not  found  this  corres- 
pondence. Still  I  do  not  consider  this  view  entirely  disproved,  and  it  should 
claim  attention  in  future  investigations. 

2.  This  is  Dr.  Hope's  explanation  of  the  second  sound  :  when  the  diastole 
takes  place,  the  blood  impelled  by  a  number  of  concurrent  circumstances,  shoots 
with  instantaneous  velocity  from  the  auricles  into  the  ventricles;  and  the  reac- 
tion of  the  ventricular  walls  on  its  particles,  when  their  course  is  abruptly  ar- 
rested by  the  completion  of  the  diastole,  is,  he  conceives,  the  cause  of  the  loud, 
brief,  and  clear  sound.  The  concurrent  circumstances  which  impelled  the  blood 
into  the  ventricles  at  the  moment  of  the  diastole,  are  the  distention  of  the  auri- 
cles in  which  the  blood  has  been  accumulating  during  the  ventricular  contrac- 
tion ;  the  weight  of  the  ventricles  collapsing  on  the  auricles  thus  distended; 
the  width  of  the  auriculo-ventricular  orifices  ;  and  lastly,  the  sucking  power  of 
the  ventricle  in  its  diastole.  With  respect  to  this  last,  Dr.  Hope  does  not  as- 
sume that  the  ventricles  have  an  actively  dilating  power  further  than  what  pro- 
ceeds from  the  physical  elasticity  of  their  parietes,  but  such  a  power  has  been 
ascribed  to  them  by  Bichat,  Pechlin,  Carson,  and  others,  and  even  by  Laennec; 
and  although  opposed  to  what  we  at  present  know  of  animal  dynamics,  it  would 
be  rash  to  absolutely  deny  the  possibility  of  its  existence.  The  injection  of  the 
coronary  arteries,  which  occurs  the  instant  the  systolic  action  ceases,  may  some- 
what contribute  to  the  dilatation  of  the  ventricles.  Whatever  be  the  cause,  the 
diastole  in  large  animals  is  sufficient  to  force  open  the  hand  of  a  person  grasping 
the  ventricles,  and  it  is  therefore  not  surprising  that  this  should  have  been  as- 
cribed to  an  actively  dilating  power.  It  is  in  favor  of  Dr.  Hope's  explanation 
of  the  second  sound,  that  it  does  not  falsify  Laennec's  signs  of  disease  of  the 
auricular  valves ;  and  although  for  acoustic  reasons  before  stated,  I  should  be 
inclined  to  place  the  seat  of  the  sound  in  the  parietes  of  the  ventricles,  rendered 
momentarily  tense  by  the  sudden  influx  of  blood,  rather  than  in  the  motions  of 
the  fluid,  I  incline  to  this  explanation  of  the  cause  of  the  second  sound. 

Since  the  first  announcement  of  M.  Majendie's  views  respecting  the  causes  of 
the  sounds  of  the  heart,  two  years  since  by  M.  Pigeaux,  as  quoted  in  the  prece- 
<  1  i i i ir  part  of  this  note  by  Dr.  Williams,  this  distinguished  physiologist  has  him- 
self  published  his  opinions  on  the  subject,  and  which,  if  they  were  formerly 
and  are  again  correctly  repoited,  seem  to  have  undergone  a  very  important 
change.  (Sec  a  translation  of  M.  Majendie's  Memoir  in  the  Medical  Gazette, 
June  98,  1834.)  He  now  attributes  the  first  sound  to  the  shock  of  the  apex  of 
the  heart  against  the  walls  of  the  chest  during  the  systole  of  the  ventricles,  and 
the  second  sound  to  a  similar  impulse  of  the  anterior  surface  of  the  right  ventri- 
cle during  the  diastole  of  the  ventricles.  The  principle  of  the  generation  of 
the  sound  is  indeed  still  the  same,  but  the  causes  of  the  individual  sounds  are  in 
some  degree  reversed.  Against  the  truth  of  M.  Majendie's  principle  many  ar- 
guments may  be  adduced,  and  even,  it  would  appear,  some  well-ascertained  facts. 
I  shall  here  state  a  few  of  these,  for  the  substance  of  which  I  am  indebted  to 
my  friend,  the  ingenious  author  of  the  first  portion  of  the  present  note. 

1.  In  the  experiments  by  Dr.  Hope  the  impression  on  Dr.  Williams's  mind  is, 
that  he  distinctly  heard  the  two  sounds  of  the  heart  when  this  organ  was  remo- 
ved from  all  contact  with  the  thoracic  parietes  and  the  pericardium,  and  when 
the  constant  and  close  apposition  of  the  stethoscope  precluded  the  possibility  of 
any  sound  being  produced  by  any  shock  against  it :  and  it  will  be  seen  hereafter 
that  M.  Bouillaud:s  conviction  is  similar. 


600  EXPLORATION    OF    THE    HEART. 

2.  To  say  nothing  of  the  inconclusiveness  of  any  arguments  deduced  from 
phenomena  elicited  under  such  an  unnatural  condition  of  things  as  existed  in 
these  experiments,  it  may  be  remarked,  that  the  third  and  fourth  are  subject  to 
fallacy,  inasmuch  as  "  the  sonorous  bodies"  and  "  the  sternum  of  the  goose" 
might  have  given  rise  to  sounds  in  consequence  of  the  existence  of  an  interval 
between  them  and  the  heart ;  a  state  of  parts  very  different  from  the  natural,  in 
which  the  heart  and  the  walls  of  the  chest  are  in  apposition,  and  which  unnatu- 
ral state  of  parts  might  have  permitted  the  organ  to  communicate  a  shock  to  the 
bodies,  utterly  impossible  in  the  natural  state. 

3.  The  facts  adduced  in  the  memoir  after  Exper.  4,  and  the  5th  and  6th  ex- 
periments, merely  indicate  that  the  sounds  of  the  heart  cannot  be  heard  through 
a  considerable  layer  of  air,  water,  or  healthy  lung,  facts  long  known  ;  but  M. 
Majendie  has  yet  to  prove  that  any  injection  of  air  or  water,  separating  the  heart 
from  the  walls  of  the  chest,  will  prevent  these  sounds  from  being  audible  over 
the  left  clavicle. 

4.  How  will  M.  Majendie  explain,  in  accordance  with  his  views,  the  incon- 
testable facts  of  the  increased  loudness  and  diminished  impulse  in  dilatation,  and 
the  converse  in  hypertrophy  ?  or  the  intensity  of  the  sounds  in  the  carotids,  and  at 
the  top  of  the  chest,  in  aneurism  of  the  arch  of  the  aorta  and  innominata,  in  which 
cases  they  are  often  heard  more  distinctly  than  in  the  region  of  the  heart  itself? 

It  would  further  appear  that  since  M.  Majendie's  paper  was  read  before  the 
Institute,  M.  Bouillaud  has  performed  a  series  of  experiments,  with  the  same 
object,  but  with  results  the  reverse  of  those  announced  by  Majendie.  The  re- 
sults of  M.  Bouillaud's  experiments  were,  that  he  could  always  hear  the  two 
sounds  of  the  heart  although  there  was  no  point  of  contact  between  the  organ 
and  any  portion  of  the  walls  of  the  chest.  He  indeed  found  that  the  friction  of 
the  heart,  against  the  end  of  the  stethoscope  gave  rise  to  a  particular  sound; 
but  this  (merely  a  sound  of  rubbing)  was  so  very  different  from  the  natural  sound 
of  the  heart  that  the  two  could  never  be  confounded.  It  was,  moreover,  ascer- 
tained, that  the  momentary  pulsation  of  the  empty  organ,  after  it  was  separated 
from  the  body  of  the  animal,  was  accompanied  by  no  perceptible  sound.  M. 
Bouillaud's  own  opinion  respecting  the  cause  of  both  the  sounds  is,  that  they 
are  owing  to  the  play  of  the  valves  of  the  heart.  (Journ.  Hebdom.  quoted  in 
Med.  Chir.  Rev.  July,  1834.)  In  reference  to  this  opinion  of  M.  Bouillaud,  as 
also  to  that  of  Dr.  Hope,  I  would  observe  that  they  both  possess  a  degree  of 
probability  in  my  mind  over  all  those  which  attribute  the  two  sounds  to  two 
different  causes.  Although  certainly  characteristically  different,  yet  the  two 
sounds  have  so  great  a  similarity  and  are  so  allied  in  time  and  place,  that  I  can- 
not readily  bring  my  mind  to  believe  that  they  do  not  both  depend  upon  one 
and  the  same  cause  slightly  modified,  or  at  least,  on  the  different  play  of  the 
same  parts.  But  the  whole  subject  wants  fresh  investigation  and  the  institution 
of  a  new  set  of  experiments  on  large  animals, — an  investigation  which  cannot 
be  entrusted  to  better  hands  than  those  of  Dr.  Hope  and  Dr.  Williams. —  Transl. 


CHAPTER  V. 


OF    CERTAIN    ANOMALIES    IN    THE    SOUND    OF    THE    HEART    AND 
ARTERIES. 

These  phenomena  are  the  most  remarkable,  inasmuch  as  they  are 
the  only  ones  discovered  by  immediate  auscultation,  which  do  not 
depend  on  structural  lesion  of  the  organs  in  which  they  are  pro- 
duced.* 

*  Such  an  assertion  I  cannot  pass  by  unnoticed.     Especially  while  acknowl- 


OF    THE    BELLOWS-SOUND. 


601 


Sect.  I. — Of  the  Bellows-sound  of  the  heart  and  arteries. 

The  heart  and  arteries,  under  certain  circumstances,  in  place 
of  the  sound  which  naturally  attends  their  dilatation,  produce 
what  T  have  denominated  the  bellows-sound,  from  the  circum- 
stance of  its  exactly  resembling,  in  the  greater  number  of  cases 
at  least,  the  noise  produced  by  this  instrument  when  used  to 
blow  the  fire.  This  comparison  is  exact ;  and  the  cardiac  sound 
is  even  frequently  as  loud  as  that  of  the  machine.  It  however 
presents  many  varieties,  some  of  which  are  so  different  from  the 
others  that  we  should  have  difficulty  in  believing  them  to  be  of 
the  same  kind,  were  it  not  from  the  rapidity  with  which  they 
succeed,  and  the  insensible  manner  in  which  they  shade  into  each 
other.     The  varieties  are  of  three  kinds. 

1.  The  bellows-sound,  properly  so  called. — This  may  accom- 
pany the  diastole  of  the  heart  and  arteries,  and  when  present,  it 
entirely  re-places  the  natural  sound  of  the  ventricle,  auricle,  or 
artery  :  it  ceases  during  the  systole.*     In  some  very  rare  instances, 

edging  that  in  a  great  number  of  instances  the  abnormal  sounds  of  the  heart 
and  arteries  axe  not  essential  to  any  lesion  which  can  be  discovered  by  dissec- 
tion. I  at  the  same  time  believe,  with  all  modern  observers,  that  in  a  very 
great  majority  of  cases,  these  different  sounds  depend  upon  alterations  which 
are  both  constant  and  appreciable. — indral. 

*  It  uniformly  happens  that  the  different  varieties  of  the  bellows-sound  are 
heard  during  the  diastole  of  the  arteries,  in  which  most  probably  it  has  its  seat. 
The  same  is  not  true,  however,  as  it  regards  the  diastole  of  the  auricles  and 
ventricles. 

The  following  are  some  observations  which  have  been  made  on  this  point. 
Generally  speaking,  the  bellows-sound  is  heard  during  the  systole  of  the  ventri- 
cles, coinciding  therefore  with  the  impulse  both  of  the  heart  and  arteries. 
Sometimes  it  is  heard  only  towards  the  close  of  the  systole,  terminating  it,  as  it 
were  :  sometimes,  on  the  contrary,  it  commences  with  it,  and  is  prolonged 
through  its  whole  extent.  When  this  happens,  the  first  sound  is  completely 
masked  by  it.  Less  frequently  the  bellows-sound  coincides  with  the  diastole  of 
the  ventricles  and  the  systole  of  the  auricles,  occurring  at  the  close  merely,  or 
existing  throughout  their  whole  duration. 

The  point  where  this  bruit  is  heard,  is  by  no  means  uniform  ;  in  some  instan- 
ces it  may  be  heard  over  the  whole  extent  of  the  precordial  region;  in  others  it 
is  confined  to  the  region  beneath  the  sternum,  under  the  ribs,  or  beneath  their 
cartilages.  It  may  be  most  distinct  near  the  apex,  the  middle,  or  near  the  base 
of  the  heart. 

As  it  regards  the  sensations  which  this  sound  conveys  to  the  ear,  they  vary 
exceedingly,  and  in  order  tliat  all  may  have  a  proper  conception  of  them,  and 
thai  any  form  of  words  may  convey  a  just  idea  of  their  real  character,  it  is  ne- 
cessarj  that  each  one  shouldohserve  them  for  himself.  The  two  denominations 
tin  In "lloirs-.souii.d,  the  sound  of  the  sum,  or  rasp,  are  perhaps  the  only  ones  which 
give  us  a  correct  notion  of  the  idea  to  be  conveyed  ;  for  when  these  phenomena 
are  well  marked,  it  seems  indeed  as  though  one  heard  the  action  of  those  in- 
struments. 

Sometimes  there  is  also  heard  over  different  parts  of  the  precordial  region  a 
kind  of  whizzing  or  hissing  noise  ;  sometimes  a  sound  of  friction  (bruit  de  frole- 
nient),  and  sometimes  indeed,  a  peculiar  sound  which  imitates  very  well  the 
cry  of  certain  animals.  In  regard  to  ail  such  phenomena,  however,  no  descrip- 
tion can  supply  the  want  of  actual  observation. 

16 


602  EXPLORATION  OF  THE  HEART. 

indeed,  the  sound,  more  particularly  in  the  carotids,  but  also  in 
the  heart,  is  changed  into  a  continuous  murmur,  like  that  of  the 
sea,  or  that  which  is  produced  by  the  application  of  a  large  shell 
to  the  ear.  In  cases  of  this  kind,  we  can  no  longer  distinguish, 
or  we  distinguish  very  imperfectly,  the  jerking  action  of  the  dia- 
stole. Sometimes  we  perceive  this  continuous  murmur  in  one  of 
the  carotid  or  subclavian  arteries,  while  that  of  the  opposite  side 
yields  the  common  bellows-sound,  answering  the  arterial  dia- 
stole. Most  commonly  the  bellows-sound  is  accurately  confined 
within  the  limits  of  the  artery  or  ventricle :  sometimes,  however, 
it  is  diffused  over  a  space  much  larger. 

2.  Sound  of  the  saw  or  rasp. — This  sound  is  exactly  like  that 
of  one  or  other,  of  the  instruments  named,  heard  more  or  less  re- 
motely, and  is  accompanied  by  the  perception  of  roughness,  con- 
veyed by  the  action  of  these  instruments. 

3.  Musical  or  hissing  bellows-sound. — This  variety  is  only  met 

The  bellows-sound,  the  sound  of  the  saw,  &c.  may  be  the  only  anormal  phe- 
nomena which  are  observed  about  the  heart.  I  have  at  this  moment  before  me, 
a  young  man,  22  years  of  age,-  who  entered  the  hospital  with  orchitis,  and  slight 
abdominal  pains,  in  whom  there  was  not  a  symptom  which  would  lead  one  to 
suspect  any  disturbance  in  the  circulating  system.  He  had  never  suffered  from 
pain  in  the  precordial  region  :  he  had  never  experienced  any  considerable  dysp- 
noea, neither  had  he  ever  had  palpitations  of  the  heart  sufficient  to  attract  his 
attention.     He  had  never  had  the  least  trace  of  an  oedema. 

On  auscultating  the  heart  it  was  observed  tha_t  the  first  sound  was  replaced  by 
a  well  marked  bellows-sound.  Beside  this,  no  other  derangement  was  noticed, 
either  in  the  impulse  of  the  heart,  its  rythm,  or  in  the  extent  or  frequency  of  its 
pulsations.  I  was  informed  that  this  individual  at  the  age  of  12  years,  had  for 
sometime  labored  under  an  attack  of  acute  articular  rheumatism. 

In  other  individuals,  some  other  morbid  phenomena  co-existed  with  the  bel- 
lows-sound of  the  heart,  such  as  an  increased  impulse,  an  irregularity  or  an 
intermittence  in  its  contractions,  &c.  The  bellows-sound  may  exist  cither  alone 
or  in  company  with  other  analogous  sounds  of  the  arteries.  We  shall  speak  of 
this  subject  more  fully  hereafter,  remarking  by  the  way  that  there  is  no  necessa- 
ry relation  between  the  heart's  sounds  and  those  of  the  arteries,  the  former  very 
frequently  existing  without  the  latter,  and  vice  versa. 

There  is  another  sound  which  accompanies  the  contractions  of  the  heart,  and 
which  appears  to  depend  upon  the  intensity  of  the  shock  of  this  organ  against 
the  thoracic  walls  ;  it  may  perhaps  depend  somewhat  upon  the  mode  of  its  con- 
tractions. This  sound  is  accompanied  with  a  very  peculiar  clicking,  which 
resembles  very  much  the  sound  which  is  produced  by  striking  upon  a  piece  of 
metal.  We  may  get  a  very  correct  idea  of  this  sound  (as  was  remarked  by  M. 
Filhos,  who  from  that  circumstance  applied  to  it  the  name  oftintement  auriculo- 
metaliique),  by  applying  the  palm  of  the  hand  on  the  concha  of  the  car,  and  then 
striking  upon  it  with  the  fingers  of  the  other  hand.  This  metallic  tinkling  of 
the  heart  is  developed  under  a  variety  of  circumstances,  wThere  the  heart  with- 
out any  organic  affection,  is  more  or  less  disturbed  in  its  actions.  Thus  it  has 
been  observed,  for  example,  in  a  great  variety  of  nervous  affections  of  this  organ, 
also  during  the  existence  of  a  slight  febrile  excitement  of  longer  or  shorter  du- 
ration. It  also  discovers  itself  in  a  great  majority  of  cases  of  organic  affections 
of  the  heart,  and  especially  in  hypertrophy  of  this  organ.  Laennec  who  had 
observed  this  bruit,  has  designated  it  by  the  name  of  metallic  tinkling.  It  may 
be  heard  most  frequently  in  the  precordial  region,  sometimes,  though  more 
rarely,  in  other  places.  Thus  M.  Bouillaud  says  that  in  two  individuals  affected 
with  a  very  extensive  inflammation  of  the  left  lung,  he  has  heard  this  sound 
very  distinctly,  near  the  fossa  infra-spinata  of  the  left  scapula.— Jlndral. 


OF    THE    BELLOWS-SOUND.  603 

with  in  the  arteries ;  at  least  I  never  observed  it  in  the  heart.* 
The  common  bellows-sound  of  the  arteries  frequently  degen- 
erates into  this,  particularly  when  the  patient  is  unusually  agi- 
tated from  any  cause,  becoming  like  the  sighing  of  the  wind 
through  a  key-hole,  or  the  sound  of  a  metallic  cord  which  still 
vibrates  long  after  being  struck.  These  sounds  are  very  distinct 
although  never  very  loud ;  and  occasionally  they  compose  a  cer- 
tain succession  of  musical  tones,  as  if  the  artery  were  become  a 
vibrating  string,  from  which  two  or  three  notes  were  drawn  out 
in  succession,  by  advancing  and  drawing  back  the  finger  upon 
it.  In  four  cases  I  have  met  with  this  sound  (which  is  literally 
musical)  in  the  carotid  arteries.f  In  one  of  these  cases,  I  at  first 
conceived  the  sound  to  arise  from  an  instrument  in  the  apart- 
ment below.  On  a  close  examination  it  was  found,  that  the  mu- 
sical notes  were  associated  with  a  slight  vibration  of  the  artery, 
which,  during  its  diastole,  seemed  to  brush  the  end  of  the  stetho- 
scope. From  time  to  time  the  melody  ceased  all  at  once,  and 
was  replaced  by  a  very  strong  sound  of  the  rasp.  This  alterna- 
tion of  sound  produced  an  effect,  of  which  I  may  give  some  idea, 
at  the  risk  of  making  a  ridiculous  comparison  : — it  was  like  the 
sound  of  military  music,  on  a  march,  every  now  and  then  inter- 
rupted by  the  hoarse  roll  of  the  drum. 

The  hissing  bellows-sound  of  the  subclavian  artery  might  some- 
times be  confounded,  by  an  inexperienced  observer,  with  sounds 
of  quite  a  different  kind.  This  is  when  the  violent  pulsation  of 
this  artery,  by  compressing  the  summit  of  the  lung,  gives  rise  to 
a  sibilous  or  mucous  rhonchus  in  some  of  the  bronchial  tubes  : 
the  cause  of  this  kind  of  rhonchus  is  readily  ascertained  from  its 
isochronism  with  the  pulse.  I  even  think  that  I  have  heard  the 
metallic  tinkling  produced  in  the  same  manner  in  a  tuberculous 
excavation. —  The  bellows-sound  of  the  heart  becomes  rarely  si- 
bilous, and  never  in  a  very  marked  degree. 

The  bellows-sound,  as  well  in  the  heart  as  arteries,  may  exist 
without  any  increase  of  the  impulse.  It  may  exist  at  the  same 
time  in  the  four  cavities  of  the  heart,  and  over  the  whole  extent 
of  the  arterial  system.  I  do  not  believe  it  ever  exists  in  the  veins. 
Sometimes,  however,  I  have  been  led  to  suspect  its  presence  in 

*I  have,  at  the  moment  of  writing  this  note,  (July  26,  1834,)  a  man  under 
my  care,  in  the  Chichester  infirmary,  in  whom  the  musical  hcllows-sound  exists 
in  the  heart,  in  the  most  striking  manner,  being  so  loud  as  to  be  distinctly  audi- 
ble without  the  stethoscope,  at  a  short  distance  from  the  person's  body.  It  is 
isochronous  with  the  contraction  of  the  ventricles,  terminating  in  the  shock  of  the 
heart.  It  resembles  exactly  the  rather  loud  and  shrill  moan  of  an  infant  or  puppy, 
which  i>  kepi  up  uninterruptedly  with  every  expiration.  Dr.  Hope  mentions  a 
similar  case  (Treatise,  p.  338,)  and  refers  to  one  by  Dr.  Elliotson,  in  which  there 
was  a  very  large  and  long  vegetation  in  the  mitral  valve. —  Transl. 

]  The  author  records  the  exact  melody  in  these  cases,  in  musical  notes,  which 
I  have  omitted,  as  being  matter  of  mere  curiosity.—  Transl. 


604  EXPLORATION  OF  THE  HEART. 

the  jugulars ;  but,  as  after  a  few  hours,  the  sound  became  syn- 
chronous with  the  carotid  pulse,  I  concluded  that  it  had  its  site 
in  this  vessel.  It  much  more  frequently  occupies  the  ventricles 
than  the  auricles  ;  sometimes,  however,  it  is  confined  to  the  lat- 
ter ;  and  very  often  it  exists  in  one  ventricle  only.  It  frequently 
is  perceived  in  a  high  degree  in  the  heart,  without  there  being 
any  similar  sound  in  the  arteries ;  more  rarely  the  reverse  is  the 
case.  It  is  usual  for  the  sound  to  be  perceived  in  a  small  num- 
ber of  arteries  at  the  same  time,  and  over  a  certain  part  of  their 
course,  without  any  thing  of  the  same  kind  being  found  in  their 
trunks  or  branches.  The  carotid  and  subclavian  arteries  are 
those  which  exhibit  it  most  commonly,  and,  next  in  order  of  fre- 
quency, the  abdominal  aorta,  the  crural  and  brachial  arteries. 
The  arteries  of  the  right  side  give  the  sound  more  frequently  and 
in  greater  degree  than  those  of  the  left  side. 

Cause  of  the  bellows-sound. — I  have  known  a  considerable 
number  of  persons  die  of  different  diseases,  acute  or  chronic, 
who  had  presented  this  phenomenon  very  distinctly,  during  the 
latter  part  of  their  life,  sometimes  during  several  months,  as  well 
in  the  heart  as  in  different  arteries ;  and  upon  the  examination  of 
whose  bodies  I  could  discover  no  organic  lesion  coinciding  con- 
stantly with  these  phenomena,  and  which  are  not  frequently  met 
with  in  subjects  who  had  never  exhibited  any  thing  of  the  kind 
during  life.  In  the  first  edition  of  this  work,  I  considered  the 
bellows-sound  of  the  heart  as  a  sign  of  the  contraction  of  the  ori- 
fices. No  doubt  it  exists  almost  always  in  this  case ;  but  since 
the  first  publication  of  my  treatise,  I  have  very  frequently  met 
with  it  in  individuals  who  had  no  lesion  of  the  sort ;  while,  on 
the  other  hand,  I  have  seen  ossifications  of  the  valves  which  were 
not  attended  by  this  sound.  I  have  likewise  frequently  observed 
it  in  the  last  agony,  and  in  other  circumstances  when  the  heart 
is  too  full  of  blood,  in  which  latter  case  it  sometimes  quickly 
yielded  to  blood-letting.  I  formerly  also  was  inclined  to  consider 
this  phenomenon  as  connected  with  the  redness  of  the  inner  coat 
of  the  arteries,  considered  by  some  modern  writers  as  an  inflam- 
matory affection  ;  but  I  have  since  then  found  the  arteries  quite 
pale  and  perfectly  sound,  in  every  case  which  I  have  had  occa- 
sion to  examine.  In  like  manner,  I  can  state  with  certainty,  that 
the  bellows-sound  of  the  heart  is  very  often  met  with  when  this 
organ  is  perfectly  healthy.  From  these  data  it  results  that  this 
phenomenon  is  attributable  either  to  an  organic  or  vital  condition 
of  the  artery — a  sort  of  spasm  or  tension — or  else  to  a  particular 
condition  of  the  blood  itself,  or  to  the  manner  in  which  it  is 
moved.     The  last  supposition  is  inadmissible,  inasmuch  as  the 


OF    THE    BELLOWS-SOUND. 


605 


phenomenon  exists  sometimes  in  one  artery  only.*  For  various 
reasons  I  consider  this  particular  sound  as  owing  to  a  real  spas- 
modic contraction  of  the  heart  or  arteries.  On  many  occasions 
I  have  been  struck  with  the  complete  resemblance  of  the  sound 
produced  by  muscular  contraction  and  that  of  the  bellows-sound.f 
In  resting  the  ear  upon  a  pillow,  if  we  contract  the  masseter  mus- 
cles, or  rather  if  we  contract  and  relax  them  alternately,  we  give 
rise  to  sounds  precisely  like  the  bellows-sound  of  the  arteries.  In 
the  following  experiment  the  resemblance  is  more  perfect  still : 
if  we  place  the  stethoscope  upon  one  of  the  condyles  of  the 
humerus  of  a  person  whose  arm  is  supported  by  an  assistant,  and 
then  cause  the  individual  alternately  to  bend  and  to  extend  the 
fore-arm  gently,  we  perceive  a  sound  exactly  similar  to  that  pro- 
duced by  the  blast  of  a  pair  of  bellows. 

In  applying  these  remarks  to  the  case  in  question,  we  can  have 
no  difficulty  in  admitting  the  possibility  of  spasm  in  an  organ  so 
completely  muscular  as  the  heart.  In  respect  of  the  arteries,  it 
may  be  said  that  the  circular  fibres,  of  which  their  middle  or 
fibrinous  coat  is  composed,  seem  to  announce  the  existence  of 
contractile  power.  But,  besides,  nothing  seems  to  prove  that  the 
muscular  is  the  only  tissue  susceptible  of  contraction  and  spasm ; 
or,  rather,  a  multitude  of  facts  prove  the  contrary.  We  find  the 
biliary  ducts  contracted  in  certain  cases  of  icterus  ;  the  urethra 
and  lachrymal  ducts  contract  manifestly  upon  the  sound  ;  and 
even  the  skin  contracts,  in  consequence  of  mental  impressions, 
exhibiting  the  appearance  commonly  called  goose-skin.."|;  On  the 
other  hand,  the  circumstances  under  which  the  bellows-sound 
arises,  and  the  rapidity  with  which  it  appears  and  disappears  in 
some  cases,  seem  to  point  it  out,  as  being  under  the  immediate 
influence  of  the  nervous  power. 

It  almost  constantly  exists  jn  the  heart  in  the  case  of  contrac- 

*  Dr.  Williams  inclines  to  the  opinion  here  renounced  hy  Lacnncc.  "lam 
myself  disposed,"  he  says,  "  to  think,  that  were  we  better  acquainted  with  the 
laws  of  the  production  of  sound,  we  might  find  that  it  may  be  excited  by  the 
motion  of  liquids,  as  well  as  by  that  of  air,  in  or  against  solids  of  a  particular 
form  ;  and  that  we  might  find  a  more  satisfactory  explanation  of  the  phenome- 
na in  question  in  the  moving  mass  of  blood  being  thrown  into  sonorous  vibra- 
tion by  some  modification  in  its  course.  Such  a  modification  might  be  produced 
by  thickening  or  irregularity  in  one  of  the  valves  of  the  heart,  or  by  spasmodic 
action  of  some  of  the  columnae  carnae,  by  an  obstacle  in  the  calibre  of  an  arte- 
ry, &c. ;  and  these  causes  might,  as  in  the  analogous  case  of  air,  render  the 
passage  of  the  blood  sonorous,  instead  of,  as  it  usually  is,  silent."  Rat.  Exp.  50. 
—  Transl. 

t  Here  the  author  enters  into  a  long  dissertation  on  the  sounds  produced  by 
muscular  contraction,  referring  to  the  experiments  of  Dr.  Wollaston,  published 
in  the  Philosophical  Transactions,  for  1810,  and  to  some  similar  ones  by  M.  Er- 
man,  of  Berlin,  recorded  in  Gilbert's  .1n?ialen,  fur  Physik,  1812.  I  omit  this 
discussion,  as  of  no  practical  value. —  Transl 

I  9ee  a  valuable  paper  by  Dr.  Monro,  "  On  the  Spasmodic  Contractions  of 
Muscular  Tubes,''  in  a  late  number  of  the  Ed.  .loum.  of  Med.  Sc. —  Transl. 


COG  EXPLORATION    OF    THE    HEART. 

tion  of  the  orifices  of  this  organ ;  it  very  frequently  occurs  in  hy- 
pertrophy or  dilatation :  but  it  is  still  more  frequently  met  with, 
both  in  the  heart  and  arteries,  in  persons  who  have  no  organic 
lesion  of  these  parts,  and  who  labor  under  various  affections. 
The  sole  disorder  which  has  appeared  to  me  constantly,  or  al- 
most constantly,  to  accompany  the  bellows-sound,  is  a  state  of 
nervous  agitation  more  or  less  marked ;  and  which  is  always 
proportioned  to  the  extent  of  the  sound,  that  is,  to  the  number 
and  size  of  the  arteries  which  yield  it.  On  the  other  hand,  we 
never  meet  with  this  sound,  in  direct  febrile  excitement,  unless 
the  individual  is  at  the  same  time  very  nervous. 

When  the  bellows-sound  exists  at  once  in  the  aorta,  the  ca- 
rotids, and  the  arteries  of  the  extremities,  the  patient  is  in  a 
state  of  extreme  anxiety  and  distress ;  if  it  is  present  in  the 
heart,  and  greater  number  of  the  arteries,  life  is  in  danger ; 
although  it  is  seldom  that  death  actually  ensues,  unless  there 
be  at  the  same  time  organic  disease  of  the  heart.  When,  on  the 
other  hand,  one  or  two  arteries  only  are  affected,  for  instance, 
the  carotid  and  subclavian,  we  cannot  always  consider  this  as 
indicating  a  state  of  disease.  The  sound  is  very  common  in  a 
slight  degree,  in  hypochondriasis  and  hysteria.  In  persons  af- 
fected with  these  diseases,  it  is  most  commonly  met  with  in  the 
subclavians  and  carotids,  and  sometimes  in  the  abdominal  aorta. 
Young  persons,  of  a  delicate  and  irritable  habit,  and  subject  to 
haemorrhage,  are  especially  susceptible  of  this  affection  ;  but  I 
have  also  met  with  it  in  hypochondriacs  in  the  decline  of  life, 
and  who  were  very  cachectic.  I  have  frequently  observed  it  in 
various  kinds  of  haemorrhage,  for  instance,  haemoptysis,  monor- 
rhagia, and  apoplexy.  On  the  other  hand,  it  is  very  uncommon 
in  cases  of  well-marked  and  pure  inflammation.  Once  only,  in 
the  case  of  a  delicate  and  irritable  child,  affected  with  croup,  I 
observed  it  over  the  whole  extent  of  the  aorta ;  and  it  continued 
more  than  two  years  afterwards.  It  is  in  the  case  of  young  per- 
sons affected  with  hypochondriasis,  that  we  can  assure  ourselves 
that  the  bellows-sound  is  a  nervous  affection.  Most  of  these 
subjects  present  it  only  momentarily  and  in  one  or  two  arteries. 
When  they  are  in  a  state  of  calmness  and  repose,  if  we  apply  the 
stethoscope  over  the  carotids  or  subclavians,  we  perceive  merely 
the  natural  sound  of  the  arteries  ;  but  if  the  patient  becomes  in 
any  way  agitated, — if  he  walks  quick,  or  coughs,  or  breathes 
deep,  or  experiences  an  emotion  of  pleasure  or  pain,  hope  or  fear, 
the  sound  of  the  arterial  pulse  changes  at  once  to  the  bellows- 
sound  (which  becomes  sometimes  hissing),  and  this  progressively 
disappears  as  the  individual  becomes  more  composed.  In  these 
cases,  after  the  complete  disappearance  of  the  bellows-sound,  we 
can  re-produce  it  by  pressing  lightly  with   the  finger   upon  the 


OF    THE    BELLOWS-SOUND. 


607 


artery,  above  or  below  the  place  where  the  stethoscope  rests ; 
and  particularly  by  alternately  increasing  and  diminishing  the 
pressure.  Sometimes  it  is  sufficient  to  rest  the  ear  rather  strongly 
upon  the  instrument.  When  the  sound  is  perceived  in  the  heart, 
or  in  an  artery,  we  can  often  excite  it  by  the  same  means  in  other 
arteries,  particularly  in  the  brachial  and  crural.  All  these  posi- 
tive and  negative  facts  tend,  I  think,  to  prove,  that  the  bellows- 
sound  is  the  consequence  of  spasm,  and  does  not  indicate  any 
organic  lesion  of  the  heart  or  arteries.  What  will  hereafter  be 
stated  respecting  the  purring  vibration,  and  certain  phenomena 
attending  pregnancy,  will  confirm  this  proposition.* 

*  M.  Andra]  regards  the  bellows-sound,  in  certain  circumstances,  as  owing  to 
an  increase  in  the  quantity  of  blood.  In  this  I  quite  agree  with  him  ;  as  also 
in  referring  the  bellows-sound  which  we  occasionally  observe  in  plethoric  sub- 
jects, in  persons  threatened  with  an  impending  haemorrhage,  and  in  the  majori- 
ty of  females  at  the  approach  of  the  catamenia,  (confined,  be  it  observed,  in 
these  latter  cases,  to  the  vessels  in  the  vicinity  of  the  spot  where  the  haemor- 
rhage is  to  take  place,)  rather  to  the  same  cause  than  to  any  modification  of  the 
innervation.  I  have  at  present  under  my  care  a  young  man  whose  heart  is 
too  voluminous,  and  yet  can  hardly  be  termed  hypertrophous,  who  frequently 
requires  venesection.  In  this  case  there  is  a  bellows-sound  habitually  present 
in  the  heart,  aorta,  subclavian,  carotid,  and  even  the  brachial  arteries  ;  and  the 
sound  is  always  stronger  when  the  necessity  for  losing  blood  is  the  greatest. 
This  fact  is,  however,  an  exception  to  the  general  rule,  as  it  is  more  common 
to  find  the  bellows-sound  increase  after  bloodletting.  In  chlorotic  females  I 
have  sometimes  found  the  sound  diminish  and  gradually  disappear  after  the  use, 
for  some  weeks,  of  steel  and  a  better  diet, — that  is,  when  the  quantity  of  blood 
was  increased  or  its  quality  changed,  or  both. —  (M.  L.) 

Struck  with  the  circumstance  of  indubitable  cases,  in  which  the  bellows- 
sound  has  been  found  to  exist  in  the  heart  without  any  organic  lesion  to  account 
for  it,  Laennec,  as  I  have  already  remarked,  has  assigned  too  much  importance 
to  the  spasmodic  action  of  the  heart  in  the  production  of  this  sound.  In  the 
present  state  of  our  knowledge,  the  following  appears  to  comprise  all  that  is 
known  by  observation,  as  to  the  various  causes  of  the  bellows-sound,  and  other 
sounds  proceeding  from  the  precordial  regions. 

These  sounds  may  be  caused  by — 

1.  An  obstruction  of  the  blood  in  traversing  the  different  orifices  of  the  heart. 

2.  An  extraordinary  reflux  of  the  blood  through  the  orifices  which  it  has 
already  traversed. 

3.  An  alteration  in  the  play  of  the  valves. 

4.  An  anormal  contraction  of  the  fleshy  or  muscular  tissue  of  the  heart. 

5.  An  augmented  power  of  impulsion  in  the  heart. 

6.  A  tumor  compressing  this  organ. 

7.  A  friction  between  the  two  portions  of  the  pericardium  in  cases  where  its 
tissues  are  diseased. 

8.  Other  causes  not  yet  sufficiently  explained  ;  these  exist  in  persons  affected 
with  chlorosis,  and  those  who  have  lost  a  great  deal  of  blood.  It  must  be  added, 
that  in  these  cases  the  anormal  sounds  of  the  heart  are  much  less  common  than 
those  of  the  arteries. 

We  will  now  examine  in  order  each  one  of  these  causes. 

1.  The  causes  which  obstruct  the  free  circulation  of  the  b^>od  through  the 
different  cavities  of  the  heart  are  various,  and  result,  if  not  constantly  and 
necessarily,  at  leesl  for  the  most  part,  in  producing  the  different  bellows-sounds, 
hissing,  grating  sounds,  &c.  This  result,  I  say,  is  not  constant  and  necessary  : 
and  in  fact,  I  have  often  found  in  post  mortem  examinations,  the  valves  of  the 
aorta  thickened  and  deformed  by  ossification ;  yet  during  life  no  uncommon 
sound  had  been  heard  in  the  heart.  This  case  appears  to  be  particularly  com- 
mon in  old  people.     It  is  not  very  uncommon,  moreover,  to  find  individuals 


608  EXPLORATION  OF  THE  HEART. 

Before  terminating  this  section  I  think  it  proper  to  say  a  few 
words  respecting   certain  phenomena,    which   an   inexperienced 

with  an  intermittent  and  irregular  pulse,  which  apparently  indicates  a  great 
obstruction  in  the  course  of  the  blood  through  the  orifice  of  the  aorta;  yet  those 
individuals,  like  the  preceding,  exhibit  no  sounds  in  the  region  of  the  heart. 

The  circumstances  which  obstruct  the  passage  of  the  blood  and  produce  these 
sounds,  are— a  change  in  the  quantity  of  the  blood  ;  a  change  in  the  diameter 
of  the  cavities  of  the  heart;  a  contraction  of  its  orifices;  and  a  rough  state  ol 
the  surface  of  the  inner  membrane  of  the  heart. 

I  have  long  since  pointed  out  the  plethoric  state  as  one  of  the  conditions  in 
which  the  bellows-sound  of  the  heart  may  arise.  The  preceding  note  of  M. 
Laennec  explains  and  confirms  my  views  on  this  head.  In  these  cases,  I  am  of 
opinion,  we  may  account  for  this  sound  by  supposing  the  cavities  of  the  heart 
momentarily  too  small,  and  its'  orifices  too  narrow  for  the  quantity  of  blood 
which,  in  a  given  time,  is  destined  to  pass  through  them.  Bleeding  may  remove 
this  sound;  but  we  shall  presently  see  that  there  are  cases  in  which  bleeding 
would  immediately  cause  such  a  sound.  Yet  I  must  add,  that  I  have  thus  far 
seen  very  few  persons  in  whom  a  simple  state  of  plethory  might  be  regarded  as 
the  true  cause  of  the  bellows-sound  of  the  heart.  This  sound  more  often  arises 
from  other  conditions  of  the  system,  which  I  shall  proceed  to  examine. 

A  change  in  the  diameter  of  the  cavities  of  the  heart  will  certainly  change 
the  sounds  which  this  organ  makes  in  beating.  The  enlargement  of  these 
cavities  has  been  regarded  by  Laennec  as  one  of  the  causes  of  the  great  increase 
of  the  sound.  I  have  often  found  a  real  bellows-sound  in  patients  who,  as  it 
appeared  upon  autopsy,  had  no  other  lesion  than  a  dilatation  of  the  cavity 
of  the  left  ventricle,  and  hypertrophy  of  the  parietes :  the  orifices  of  the  heart 
were  of  the  ordinary  calibre,  and  the  valves  in  a  perfectly  sound  state.  Cases 
analogous  have  been  observed  by  M.  Bouillaud  :  only  he  remarks  that  in  these 
cases,  the  bellows-sound  was  heard  only  at  intervals,  and  was  not  distinct  except 
in  those  moments  when  fatigue,  effort  or  emotion,  caused  a  more  violent  move- 
ment of  the  heart  than  common. 

There  is  another  case,  the  inverse  of  this,  where  a  bellows-sound  is  heard  in 
the  heart :  namely,  when  the  cavities  of  this  organ  contract,  either  from  atrophy 
or  a  concentric  hypertrophy  of  their  parietes.  I  think  it  clear,  that  such  a  state 
of  the  heart  would  have  the  same  influence  as  a  contraction  of  its  orifices  in 
producing  anormal  sounds. 

Concretions  of  blood  sometimes  form  in  the  heart  during  life.  In  whatever 
part  of  this  organ  they  occur,  they  diminish  the  space  which  is  occupied  by  the 
blood  in  its  course,  and  consequently  may  give  rise  to  anormal  sounds,  particu- 
larly the  bellows-sound.  But  great  caution  is  here  necessary  :  where  an  au- 
topsy of  the  body  does  not  explain  the  anormal  sounds  heard  during  life,  we 
must  not  too  hastily  ascribe  their  production  to  the  clots  of  blood  found  in  the 
heart,  because  these  are  often  formed  after  death.  I  shall  recur  to  this  subject 
again. 

The  contraction  of  one  of  the  orifices  of  the  heart,  from  whatever  cause  it 
may  arise,  whether  congenital  or  superinduced,  is  the  most  important  and  the 
most  frequent  of  all  the  morbid  states  which  cause  the  bellows-sound— sound 
of  the  rasp,  saw,  &c.  In  these  cases,  the  sounds  sometimes  arise  slowly  during 
a  chronic  affection  of  the  heart;  sometimes  they  come  on  suddenly,  and  are 
the  first  symptom  of  such  a  malady.  This  is  the  case  in  particular,  where,  in 
acute  articular  rheumatism,  the  inner  membrane  of  the  heart  surfers  inflammation. 
Here  the  sounds  may  be  occasioned  either  by  a  sudden  thickening  of  the  inner 
membrane  of  the  heart,  particularly  the  part  lining  the  orifices  and  the  valves ; 
or  by  an  obstruction  of  the  blood  itself,  in  coagulating  and  collecting  in  a  sort 
of  crystalization  at  the  points  where  the  membrane  has  lost  its  smoothness  in 
consequence  of  inflammation,  in  the  same  manner  that  we  see  the  blood  col- 
lect and  harden  in  veins  which  are  inflamed. 

Finally,  there  are  cases  where  the  rasp  and  grazing  sound  appear  to  be  occa- 
sioned solely  by  an  inequality  or  roughness  of  the  surface  of  the  valves,  or  a 
thickness  of  the  same  in  certain  points. 

2.  There  is  a  certain  morbid  state  which  was  unknown  to  Laennec,  and  which 


OF    THE    BELLOWS-SOUND. 


609 


observer  might  sometimes  mistake  for  the  bellows-sound.  1.  I 
formerly  noticed  the  metallic  clicking  or  jingle  produced  in  cea- 

aflects  the  valves  of  the  heart  in  such  a  manner  that  they  allow  the  blood  to 
return  to  the  cavity  from  which  it  had  just  issued.  This  causes  at  every  motion 
01  the  heart,  a  sound  similar  to  that  arising  from  a  contraction  of  one  of  the  orifices, 
only  it  takes  place  at  a  different  moment.  Thus  supposing  one  of  the  auriculo- 
ventricular  valves  to  be  affected,  the  bellows-sound  will  coincide  with  the  mo- 
ment of  the  systole  of  the  ventricles,  or,  in  other  words,  with  the  first  sound  of 
the  heart.  If,  on  the  contrary,  the  affection  is  in  the  arterial  valves,  the  bellows- 
sound  will  be  heard  during  the  diastole  of  the  ventricles,  or  in  other  words, 
during  the  second  sound  of  the  heart.  The  sound,  in  this  case,  seems  to  result 
from  the  friction  of  the  current  of  the  blood  against  the  orifices  of  the  heart, 
repelled  by  the  elasticity  of  the  artery  towards  the  valves,  which  are  unable  to 
close  and  obstruct  the  return  of  the  blood  to  the  cavities.  This  sound  will  be 
more  distinct  if  the  valves  have  any  roughness  or  inequality  upon  the  surface  or 
edges  ;  and  this  is  most  commonly  the  case. 

:{.  It'  the  arterial  or  auriculo-ventricular  valves  have  any  effect,  by  elevation 
or  depression,  in  causing  the  sounds  of  the  heart,  it  follows  that  every  change 
in  the  natural  play  of  these  valves,  and  every  change  in  their  degree  of  tension 
or  elasticity,  &c.  must  produce  a  corresponding  change  in  the  sounds. 

4.  Although  in  a  normal  state,  the  contraction  of  the  fleshy  tissue  of  the  heart, 
appears  not  to  be  the  chief  cause  of  these  sounds,  it  is  yet  highly  probable  that 
when  this  contraction  is  very  strong,  it  changes  the  sounds  of  the  heart  as  well 
as  their  duration.  For  example,  when  the  coats  of  the  left  ventricle  are  much 
thickened,  the  first  sound  is  not  prolonged,  and  for  the  most  part  is  not  heard 
at  all. 

5.  What  I  have  said  of  the  influence  of  this  contraction,  upon  the  sounds, 
may  he  said  also  of  the  influence  of  an  augmented  impulsion  of  the  heart  against 
the  walls  of  the  chest.  I  think  it  at  least  very  probable,  that  the  metallic  clink 
arises  from  this  cause,  although  it  may  also  lie  ascribed  to  the  sudden  rising  of 
the  valves.  Certain  affections  of  the  tissue  of  the  valves  may  also  concur  in  its 
production. 

6.  Reasoning  and  analogy  have  alone  led  to  the  supposition  that  a  tumor 
around  the  heart  sufficiently  powerful  to  obstruct  the  passage  of  the  blood  might 
cause  the  bellows-sound.  To  produce  this  effect,  the  tumor  must  be  very  large, 
and  affect  the  fleshy  tissue  of  the  heart,  as  in  certain  cases  of  cancers  in  this 
organ,  referred  to  by  me  elsewhere. 

7.  The  diseases  of  the  pericardium  may  also  give  rise  to  sounds  in  the  pre- 
cordial regions;  in  particular  the  numerous  varieties  of  the  sounds  of  friction. 
I  think  it  very  rare  that  the  bellows-sound  is  caused  by  a  simple  affection  of  the 
pericardium,  without  any  lesion  of  the  internal  membrane  of  the  heart.  M. 
Bouillaud.  who  at  first,  in  an  article  of  the.  Dictionaire  de  Medicine  and  Ckirur- 
gic  pratiques,  had  admitted  that  the  bellows-sound  might  arise  from  an  affection 
of  the  pericardium,  announces  a  different  opinion  in  his  Truite  des  Maladies  du 
ccc.ur,  and  on  this  point  agrees  with  me.  He  remarks  with  justice,  that  the  com- 
plication of  pericarditis  with  inflammation  of  the  inner  membrane,  may  easily 
lead  to  mistakes.  In  this  case  the  former  of  these  diseases  is  wrongly  supposed 
to  be  the  cause  of  many  phenomena  arising  from  the  latter;  an  error  the  more 
natural,  as  the  symptoms  of  pericarditis,  being  more  striking,  and  more  generally 
known,  are  more  particularly  the  object  of  attention. 

S.  In  all  the  cases  above  enumerated,  the  various  anormal  sounds  in  the  re- 
gion of  the  heart  may  be  accounted  for  mechanically  :  but  there  are  others,  of 
which  a  precise  explanation  cannot  be  given.  All  we  know  is  that  these  sounds 
(w  Inch,  differing  rather  in  degree  than  in  their  nature,  may  be  comprehended 
under  the  general  term  of  bellows-sounds.)  coincide  with  certain  well  known 
conditions  of  the  system,  such  as  an  alteration  of  the  blood  occasioned  by  a 
diminution  of  its  quantity  or  of  some  one  of  its  components.  I  do  not  think  it 
clear  that  hysteria  or  any  other  nervous  affection  without  this  state  of  the  blood, 
can  giro  rise  to  a  bellows-sound  either  in  the  heart  or  arteries.  Ought  we  in 
such  a  case  to  suppose  that  a  spasmodic  contraction  of  the  orifices  of  the  heart, 
obstructs  the  passage  of  the  blood  and  causes  this  sound  in  the  same  manner  that 
77 


596  EXPLORATION    OF    THE    HEART. 

tain  cases,  during  percussion  of  the  chest.  Sometimes  we  observe 
a  slight  jingle  of  the  same  kind  in  the  cardiac  region,  in  persons 
affected  with  nervous  palpitations,  when  the  heart  beating  with 
quickness  and  .violence,  but  with  little  real  impulse,  the  point  of 
it  only  comes  in  contact  with  the  walls.  At  each  pulsation  of 
the  ventricles,  in  this  case,  a  slight  clicking,  or  jingle  is  heard, 
as  if  originating  within  the  tube  of  the  stethoscope  and  traversing 
it.  2.  In  other  cases,  I  have  perceived  in  the  same  place,  but 
more  profoundly,  a  sound  like  the  creaking  of  a  new  saddle. 
I  for  some  time  imagined  that  this  sound  might  be  a  sign  of 
pericarditis,  but  I  afterwards  convinced  myself  that  this  was  a 
mistake.  I  have  since  thought  that  it  occurred  in  cases  where 
the  heart,  of  large  size,  or  distended  with  blood,  is  rather  con- 
fined in  the  lower  mediastinum,  and  when  there  is  some  air  in 
the  pericardium  ;  and  also  in  another  case,  to  be  noticed  pre- 
sently.* 3.  In  some  persons  the  pleura  and  anterior  edge  of 
the  lungs  extend  before  the  heart  so  as  to  cover  it  almost  entirely. 
If  we  examine  a  subject  of  this  kind  during  strong  action  of  the 
heart,  we  find  that  the  ventricles,  during  dilatation,  compress 
these  portions  of  lung,  and  thereby  modify  the  respiratory  sound 
so  as  to  make  it  more  or  less  resemble  the  bellows-sound.  4. 
Lastly,  a  mistake  may  originate  from  the  sound  of  muscular  con- 
traction in  the  vicinity  of  the  artery  we  are  exploring,  as  from 
the  action  of  the  mastoid  muscles  in  the  vicinity  of  the  carotids : 
but  this   error  cannot  be   committed,  without  great  inattention.f 

a  spasmodic  contraction  of  the  constrictor}-  muscles  of  the  glottis  may  create 
certain  sudden  difficulties  in  the  passage  of  the  air  through  the  larynx? — 
Andral. 

The  bellows-sound,  sometimes  alone  but  more  frequently  accompanied  by  the 
jarring  tremor,  is  very  constantly  present  in  the  external  thyroid  arteries  in 
cases  of  bronchocele  of  considerable  size  ;  and  I  have  observed  it  gradually  to 
disappear  as  the  tumor  was  absorbed  under  the  use  of  iodine. —  Transl. 

*  We  shall  hereafter  find,  when  treating  of  pericarditis,  that  this  sound  of  the 
saddle,  or  leather-creak,  is  in  reality  what  Laennec  first  supposed  it  to  be,  a  sign 
of  pericarditis,  and  a  very  important  one — Transl. 

t  In  the  preceding  section  I  do  not  think  that  Laennec  has  sufficiently  sepa- 
rated what  is  of  practical  utility  from  what  is  merely  curious.  It  is  impossible, 
in  my  opinion,  to  refer  the  bellows-sound,  the  rasp-sound,  and  the  leather-sound, 
to  the  same  cause,  much  less  to  make  them  out  to  be  of  equal  value  as  signs. 
The  pure  bellows-sound  appears  to  be  a  merely  vital  phenomenon,  either  de- 
pendent on  the  state  of  the  innervation  or  on  some  modification  in  the  quantity 
or  quality  of  the  blood:  while  the  rasp-sound  and  leather-sound  are  invariably 
connected  with  Well-marked  organic  lesions.  The  first,  when  heard  in  the  re- 
gion of  the  heart  (and  notwithstanding  the  opposite  authority  of  my  revered 
master,  I  must  deny  that  it  has  ever  been  heard  elsewhere)  is  a  certain  index  of 
a  mechanical  obstacle  to  the  course  of  the  blood,  being  indeed,  as  we  shall  see 
hereafter,  the  pathognomonic  sign  of  the  cartilaginous  or  bony  induration  of 
the  valves, — that  is  to  say,  provided  it  be  constantly  present  after  it  is  once  pro- 
duced. The  leather-creak  is  equally  pathognomonic  of  pericarditis  with  very 
slight  or  with  no  effusion — that  is,  of  a  pericardium  having  its  free  surface  be- 
come rough  and  unequal. — (M.  L.) 

I  cannot  admit  Laennec's  explanation  of  the  anormal  sounds  in  the  arteries. 
It  is  mere  hypothesis  to  ascribe  their  cause  to  a  modification  of  the  nervous  sy.s- 


THE    PURRING    VIBRATION. 


611 


Sect.  II. — Of  the  Purring  or  Whirring  Vibration  Tremor  or 
Thrill  of  the  Heart  and  Arteries. 

I  noticed  under  this  name  in  the  first  edition   of  the  present 
work,  a  particular  sensation  perceived  by  the  hand  in  the  cardiac 

tern.  It  is  true  they  are  often  heard  in  nervous  patients,  but  only  when  they 
have  other  disorders  which  may  be  the  real  causes.  It  is  not  clear,  as  Laennec 
would  have  us  believe,  that  these  sounds  are  particularly  common  in  hypochon- 
driacal persons,  and  that  a  certain  degree  of  nervous  agitation  is  sufficient  to 
create  them. 

The  anormal  sounds  of  the  arteries  may  be  continuous  or  intermittent.  M. 
Bouillaud  has  very  justly  compared  one  of  the  most  common  to  the  sound  of 
the  child's  toy  called  (Liable,  (humming-top.)  The  same  artery  may  exhibit  by 
turns  the  continuous  and  intermittent  bellows-sound.  One  of  the  most  curious 
varieties  is  that  which  resembles  the  buzzing  of  a  fly,  (bruit  de  mouche.) 

I  have  always  observed  the  anormal  sounds  of  the  arteries  at  the  same  moment 
with  the  first  sound  of  the  heart,  that  is,  during  the  systole  of  the  ventricles  and 
the  arterial  diastole. 

These  sounds  have  been  heard  in  the  most  of  those  arteries  which  are  suffi- 
ciently large  or  near  the  surface  to  display  their  pulsations  either  to  the  ear  or 
the  touch.  I  have  ascertained  their  existence  along  the  whole  dorsal  portion 
of  the  vertebral  column  ;  and  here  the  sound  evidently  had  its  seat  in  the  de- 
scending aorta  of  the  chest.  It  is  not  very  rare  to  hear  the  same  sound  in  the 
humeral  and  radial  arteries,  in  the  femoral  arteries,  wherever  their  pulsations 
are  perceptible  to  the  finger.  In  these  arteries  I  have  never  heard  any  but  the 
intermittent  sound:  it  is  continuous  only  in  the  carotids.  According  to  M. 
Bouillaud,  the  anormal  sounds  of  the  carotids  are  more  common  and  more  distinct 
in  the  left  artery  than  in  the  right.  1  cannot  agree  with  him  :  on  the  contrary, 
numerous  observations  have  convinced  me  that  they  are  most  common  in  the 
right;  and  this  is  Laennec's  opinion  also.  It  is  rare  to  find  these  sounds  in  the 
other  arteries  when  they  are  not  heard  in  the  right  carotid ;  yet  in  a  few  cases 
I  have  heard  the  bellows-sound  only  in  the  left. 

In  whatever  artery  the  bellows  or  any  other  anormal  sound  is  heard,  it  may 
be  weakened  or  suppressed  for  a  moment  by  pressure.  M.  Bouillaud  remarks 
that  in  certain  cases,  by  removing  the  larynx  to  a  distance  from  the  carotid 
artery,  the  bellows-sound  in  the  artery  diminished  or  ceased,  and  returned  on 
the  return  of  the  larynx  to  its  place.  Dr.  Donne  also  ascertained  that  when  a 
person  with  the  carotid  sound  made  a  strong  effort,  the  sound  suddenly  disap- 
peared. 

The  cases  in  which  the  arterial  diastole  is  attended  by  an  uncommon  sound, 
seem  to  be  the  following,  which  comprise  morbid  conditions  very  different  from 
each  other. 

1.  Diseases  of  the  tissue  of  the  Arteries.  An  inflammation  of  these  vessels, 
or  accidental  productions  in  their  coats,  may  cause  these  sounds.  The  mode  in 
which  the  sounds  arise  may  be  explained  thus.  At  each  contraction  of  the  left 
ventricle,  the  arterial  diastole  taking  place  imperfectly  from  a  want  of  elasticity 
in  the  diseased  artery,  the  blood  passes  through  a  more  narrow  passage  than 
common,  which  causes  a  friction  and  anormal  sounds,  just  as  these  sounds  are 
produced  in  the  heart. 

2.  Stricture  of  the  arteries  by  a  tumor.  I  have  ascertained  the  existence  of  an 
intermittent  bellows-sound  in  the  left  carotid  in  a  case  where  the  artery  was 
compressed  by  an  enormous  goitre.  M.  Bouillaud  heard  the  same  sound  in  the 
iliac  arteries  of  a  woman  who  bad  a  tumor  in  the  left  ovary.  Yet  such  cases 
are  uncommon,  because  the  bellows-sound  can  arise  only  when  the  tumor  com- 
presses the  artery  so  strongly  as  to  overcome  the  force  with  which  the  blood  in 
its  passage  from  the  heart  disturbs  the  artery  and  augments  its  calibre.  This  is 
the  reason,  doubtless,  why  the  pressure  of  a  stethoscope  on  an  artery  will  not 
always  cause  a  sound.  To  produce  this  effect,  the  impulsive  force  of  the  heart 
must  be  greatly  reduced 


/ 


612  EXPLORATION  OF  THE  HEART. 

region,  and   which  I  considered  with  Corvisart,  who  I  believe 
first  observed  it,  as  a  sign  of  ossification  of  the  valves,  and  par- 

3.  Diseases  of  the  Heart.  Here  again,  as  in  the  former  cases,  we  have  for  the 
most  part,  only  the  intermitting  sound.  Many  disorders  of  the  heart  may  be 
the  cause.  In  a  hypertrophy  of  the  walls  of  the  left  ventricle,  the  blood  being 
driven  with  extraordinary  lone  into  the  aorta,  causes  a  great  friction  in  the 
whole  arterial  trunk.  On  this  supposition,  we  see  thai  under  the  influence  of 
mere  nervous  palpitations,  the  heart  contracts  with  unaccustomed  foree;  the 
friction  of  the  blood  in  the  arteries  augments  in  proportion,  and  the  vessels 
which  receive  it  give  rise  to  a  sound.  Suppose  on  the  contrary,  a  diminution  of 
power  in  the  action  of  the  heart,  cither  from  a  wasting  of  its  walls,  or  a  general 
weakness  of  the  system,  in  which  this  organ  participates;  there  will  be  too  lit- 
tle strength  in  the  heart  to  dilate  the  arteries  at  each  contraction  of  the  ventri- 
cles; and  if  the  quantity  of  blood  he  large,  it  will  traverse  passages  of  too 
small  calibre  to  receive  it;  a  great  friction  is  caused,  and  the  bellows-sound  is 
thus  produced. 

There  is  yet  another  disease  of  the  heart  already  mentioned,  in  which  the 
valves  of  the  aorta,  becoming  feeble,  allow  the  blood  to  return  to  the  heart  dur- 
ing the  ventricular  diastole.  In  this  case,  at  the  moment  of  the  reflux,  than; 
may  he  heard  in  the  region  of  the  heart,  in  the  aorta,  and  in  most  of  the  great 
branches  of  the  arteries,  a  bellows-sound  differing  from  all  other:;  as  to  the  mo- 
ment when  it  occurs;  this  is  immediately  after  the  first  sound  of  the  heart, 
during  the  diastole  of  the  ventricles,  and  the  arteries  having  just  dilated,  begin 
to  collapse.  Dr.  Guyot,  who  has  written  an  excellent  work  on  the  weakness  of 
the  valves  of  the  heart,  has,  in  my  opinion,  satisfactorily  explained  this  pheno- 
mena by  the  friction  of  the  blood  in  its  retrograde  course  against  the  edges  of 
the  diseased  sigmoid  valves,  against  the  coats  of  the  ascending  aorta  and  those 
of  its  great  branches. 

4.  Nervous  Diseases.  In  applying  the  stethoscope  to  the  carotid  arteries  of 
persons  afflicted  with  hysteria,  hypochondriasis  or  epilepsy,  I  have  never  heard 
any  uncommon  sound  unless  there  was  at  the  same  time  anaemia,  chlorosis,  or 
disease  of  the  heart.  If  a  sound  be  heard  in  such  cases,  it  can  only  he  ex- 
plained by  supposing  a  spasmodic  contraction  of  the  arteries,  which  by  dimin- 
ishing their  calibre,  increases  the  friction  of  the  blood.  But  as  yet  we  have  no 
good  evidence  of  the  existence  of  a  contractile  1  issue  in  the  coats  of  the  arteries 
Yet  nervous  affections  may  sometimes  cause  the  bellows-sound  in  the  arteries  : 
because  this  may  be  produced  otherwise  than  by  a  spasm  of  the  arterial  tissue. 
We  are  not  acquainted  with  all  the  various  and  delicate  modifications  which 
maybe  brought  about  in  the  solids  or  liquids  of  the  human  body,  by  nervous 
affections.  Laennec  has  spoken  ofthe  gas  developed  in  the  heart  and  vessels  in 
consequence  of  certain  troubles  in  the  nervous  system.  We  have  do  positive 
proof  of  this:  but  is  it  unreasonable  to  suppose  it  takes  place  here,  when  we 
find  the  same  phenomena  elsewhere?  What  is  more  common,  for  example,  than 
hysterical  tympanitis?  and  how  can  this  disease  he  explained  otherwise  than 
by  supposing  that  a  disturbance  of  the  nervous  system  causes  the  blood  in  the 
innumerable  vessels  of  the  intestinal  mucous  membrane  to  evolve  certain  ele 
ments  in  the  form  of  gas?  Do  we  know  furthermore,  the  nature  ofthe  mysteri- 
ous power  which,  under  the  influence  of  passion,  throws  the  blood  with  the 
rapidity  of  lightning  into  the  capillary  vessels  ofthe  facer* 

5.  Alterations  of  the  Blood.  These  are  doubtless  the  most  frequent  and  the 
most  active  causes  of  anormal  sounds  in  the  arteries  :  and  it  is  under  their  influ- 
ence that  the  intermitting  sound  of  the  arteries  changes  to  a  continuous 
sound,  and  the  bruit  de  diable  is  produced.  This  sound  has  its  maximum  in 
chlorosis,  so  that  M.  Bouilland  proposes  to  call  this  continuous  sound  of  the 
arteries  by  the  name  of  bruit  chlorotique.  Since  this  sound  was  discovered  by 
him  in  young  females  affected  with  chlorosis.  1  have  constantly  found  it  in  like 
circumstances  :  and  in  cases  where  the  other  symptoms  ofthe  disease  were  so  im- 
perfectly developed  as  to  leave  a  doubt,  the  bruit  de  diable  in  the  carotid  arteries 
has  been  a  sure  guide  in  the  diagnosis.  In  such  cases  I  never  hesitated  to  ad- 
minister preparations  of  iron.  On  the  contrary,  in  cases  where  in  certain  chlo- 
rotic  symptoms  the  bruit   dc  diable  did  not  ex"ist.  these  medicines  have  had  no 


THE    PURRTNG    VIBRATION. 


613 


ticularly  of  the  mitral.  This  phenomenon,  no  doubt,  is  met 
with  in  almost  every  case  of  considerable  contraction  of  the  ori- 

effect.  The  sound  often  begins  to  be  heard  at  a  period  when  the  other  symp- 
toms of  the  disease  are  yet  indistinct ;  it  acquires  force  as  these  symptoms  be- 
come  more  strongly  marked;  and  sometimes  continues  in  great  power  after  the 
disease  has  much  abated.  So  long  as  it  remains,  I  think  it  well  to  continue  the 
preparations  of  iron  :  otherwise  the  chlorosis  will  be  apt  to  return.  In  this  dis- 
ease, the  bruit  de  diablt  is  not  the  only  sound  heard  :  there  is  also  the  intermit- 
ting sound,  and  sometimes  the  peculiar  sound  called  bruit  dc  moucke. 

In  scurvy,  where,  as  in  chlorosis,  the  blood  is  affected,  the  bellows-sound  lias 
been  heard  in  the  arteries.  In  a  young  man  who  was  under  my  care  in  the 
Hospital  of  La  Pitie  in  October.  1835,  it  was  very  distinct.  This  patient  had  all 
the  symptoms  of  the  most  inveterate  scurvy  :  he  had  suffered  frequent  haemor- 
rhages from  the  nose,  and  li is  whole  skin  was  covered  with  pectoral  spots.  The 
chlorotic  sound  was  heard  in  all  the  great  arteries  where  the  stethoscope  rould 
be  placed,  as  also  in  the  region  of  the  heart.  On  opening  the  body,  no  lesion 
was  discovered  in  the  circulatory  apparatus,  nor  any  other  remarkable  alteration 
except  ecchvmosis  in  the  mucous  and  serous  membranes.  I  have  recently  seen 
another  individual  attacked  with  purpura  k&morrhagica,  who  in  a  short  space  of 
time  had  suffered  abundant  bleeding  from  the  surface  of  the  greater  part  of  the 
mucous  membrane.  In  this  patient  I  found  a  very  strong  continuous  bellows- 
sound  in  the  right  carotid  artery.  This  was  the  true  chlorotic  sound,  or  bruit 
de  diable. 

The  same  sound  is  very  often  heard  in  some  of  the  arteries,  especially  the 
carotids  of  females  suffering  from  frequent  and  abundant  haemorrhages  in  conse- 
quence of  cancer  in  the  uterus.  I  found  it  in  a  man  with  the  piles  who  had 
undergone  profuse  bleeding  at  the  anus  :  he  had  at  the  same  time  dyspnoea, 
palpitations,  indigestion,  and  all  the  symptoms  of  chlorosis. 

Finally,  the  various  anormal  sounds  of  the  arteries,  particularly  the  bruit  dc 
diable,  are  frequently  heard  in  persons  who  have  lost  much  blood  in  a  short 
space  of  time.  In  this  point,  individuals  differ  remarkably.  In  some  I  have 
known  the  right  carotid  artery  to  give  a  fine  bellows-sound  in  consequence  of  a 
single  bleeding. 

What  is  the  cause  of  the  bellows-sound  of  the  arteries  in  this  5th  class  ?  Is  it 
the  deficiency  of  the  blood  which  enters  the  arteries  at  eacli  contraction  of  the 
ventricles;  the  heart  not  impelling  it  with  sufficient  force  to  distend  these  ves- 
sels properly,  and  thus  narrowing  the  channels  through  which  the  blood  passes, 
and  augmenting  the  friction  of  this  fluid  ?  If  this  be  the  cause,  which  I  am  far 
from  affirming,  the  immediate  cause  of  the  arterial  sound,  in  chlorotic  and  anae- 
miated  subjects,  must  be  the  same  as  in  the  case  of  the  preceding  classes. 

9.  This  class  differs  from  all  the  others,  in  the  circumstance  that  the  cases  are 
not  homogeneous  or  marked  by  any  common  feature.  It  comprehends  a  num- 
ber of  different  morbid  states,  in  which  I  have  discovered  the  bellows-sound 
without  any  of  the  lesions  enumerated  in  the  foregoing  series.  Thus  I  have 
found  sometimes, the  carotid  sound  in  females  laboring  under  cancer  of  the 
uterus,  at  a  period  when  no  haemorrhage  had  taken  place  from  the  uterus,  and 
there  had  not  been  sufficient  leucorrhcea  to  cause  exhaustion. — Andnd. 

In  reference  to  these  adventitious  sounds,  collectively  and  individually,  1 
think  the  following  conclusions  may  be  deduced  from  the  consideration  of 
them  : — 

1.  The  source,  of  the  sounds  is  soma  impediment  to  the  usual  current  of  the 
blood,  from  some  physical  alteration  in  the  channel  through  which  it  passes, 
whereby  such  vibrations  arc  excited  in  the  column  of  fluid  as  to  give  rise  to 
audible  sound. 

2.  The  alteration  in  the  channel  may  be  merely  temporary,  and  produced  in 
parts  possessing  a  healthy  structure,  from  nervous  causes,  from  want  of  the 
natural  harmony  of  proportion  between  the  size  of  the  channel  and  its  contents, 
and  probably  from  other  unknown  causes.  The  more  common  cause,  however, 
is  some  fixed  physical  alteration  in  the  channels  conveying  the  blood  ;  either  a 
contraction  or  enlargement  of  calibre,  or  some  other  deviation  from  the  natural 
structure,  whereby  the  current  is  more  or  less  impeded  or  disturbed. 


614  EXPLORATION  OF  THE  HEART. 

fices ;  but  since  the  first  publication  of  my  treatise,  I  have  fre- 
quently met  with  it  in  cases  where  no  organic  lesion  existed.* 

3.  We  are  not  justified,  by  the  mere  presence  of  any  of  these  sounds,  in  con- 
cluding that  organic  diseases  of  the  valves  or  valvular  orifices  exist. 

4.  If  the  morbid  sounds  disappear  after  repose,  bloodletting,  or  other  form  of 
depletion,  or  without  any  evident  cause,  we  may  suspect  that  they  originate  in 
mere  functional  disorder;  and  the  probability  of  this  opinion    will  be  im 

in  proportion  to  the  period  of  their  absence. 

5.  If  they  are  not  removed  by  these  or  any  oilier  causes,  or  if  they  are  remov- 
ed for  a  very  short  period  only,  or  are  merely  lessened  in  degree,  we  may  con- 
clude that  they  originate  in  diseases  of  the  valvular  orifices;  and  this  conclu- 
sion will  be  still  further  strengthened  if  there  exist  other  symptoms  of  diseased 
heart. 

6.  The  probability  of  organic  disease  is  increased  in  proportion  as  the  charac- 
ter of  the  sounds  approaches  that  of  the  sound  of  the  saw  or  rasp. 

7.  The  sounds  produced  by  valvular  disease  become  much  weaker  when  the 
contraction  of  the  orifice  is  extreme  than  when  it  is  moderate,  a  certain  extent 
and  force  of  current  being  requisite  to  produce  them  in  the  highest  degree.  Dr. 
Hope  says,  that  he  has  often  found  that  when  the  orifice  was  reduced  to  a  crev- 
ice of  two  or  three  lines  in  width,  no  sound  whatever  was  produced. 

8.  The  following  is  a  brief  sketch  of  the  rationale  of  the  morbid  or  anormal 
sounds  resulting  from  valvular  disease,  for  which  we  are  indebted  to  the  able 
physician  just  named. 

a.  When  the  aortic  orifice  is  contracted,  an  adventitious  sound,  or  morbid 
murmur,  accompanies  the  ventricular  systole  and  first  sound  ;  and  when  the 
valves  not  closing  accurately,  permit  regurgitation  from  the  aorta,  a  morbid  mur- 
mur accompanies  the  diastole  and  second  sound  also;  but  this  last,  when  it  oc- 
curs, is  extremely  slight  and  brief,  as  the  influx  of  blood  from  the  auricle,  dur- 
ing the  diastole,  almost  instantly  puts  an  end  to  any  regurgitation  capable  of 
producing  sound. 

b.  When  the  pulmonic  orifice  is  contracted,  the  effects  are  the  same  ;  but 
disease  of  the  valves  on  this  side  of  the  heart,  as  will  be  shown  in  another  place, 
is  comparatively  very  rare. 

c.  When  the  mitral  orifice  is  contracted,  a  morbid  murmur  accompanies  and 
sometimes  entirely  supersedes  the  second  sound,  being  occasioned  by  the  pas- 
sage of  the  blood  from  the  auricle  into  the  ventricle  during  the  diastole  of  the 
latter.  When  the  valve,  not  closing  accurately,  admits  of  the  regurgitation,  a 
murmur  accompanies  the  first  sound,  and  this  is  sometimes  excited  by  a  degree 
of  disease  insufficient  to  produce  it  during  the  second. 

d.  When  the  tricuspid  orifice  is  contracted,  the  results  are  the  same  as  in  the 
last  case.      (Cyc.  of  Pract.  Med.  vol.  i.  Art.  Auscultation.) — Transl.  • 

*  We  suspect  Laennec  is  here  under  a  bias  in  referring  the  cause  of  most  of 
the  anormal  sounds  of  the  heart  and  arteries  to  a  nervous  affection.  For  my 
part,  I  can  say  that  in  every  case  where,  after  death,  I  have  examined  the  heart 
of  a  person  who  had  exhibited  for  any  length  of  time,  the  premiss tmeni  cataire, 
or  purring  thrill,  I  have  found  in  one  of  the  orifices  of  the  heart  or  in  the  peri- 
cardium, lesions  sufficient  to  account  for  it.  These,  in  a  great  many  instai 
were  ossifications  which  affected  the  valves  and  rendered  their  surfaces  unequal, 
At  other  times  they  were  thickenings  of  these  membranes.  In  other  cases  the 
heart  was  sound,  but  the  inner  surfaces  of  the  pericardium  were  lined  with  false 
membranes,  which  sufficiently  explained  the  sound.  It  may  happen  that  1  his 
phenomenon,  after  continuing  very  distinct,  declines,  and  finally  ceases  alto- 
gether. It  was  doubtless,  this  description  of  cases  which  Laennec  had  in  view, 
when  he  attributed  the  premissemeni  to  a  simple  affection  of  the  nerves.  In 
the  instances  where  I  witnessed  the  disappearance  of  the  phenomenon,  there 
were  at  the  same  time,  other  signs  of  organic  affection  of  the  heart:  the  disap- 
pearance of  the  sound  did  not  convince  me  that  it  was  a  nervous  phenomenon, 
but  that  it  was  owing  to  a  momentary  lesion  of  the  valves.  Why,  for  example, 
could  it  not  arise  from  a  temporary  and  acute  inflammatory  action  of  the  valves, 
causing  a  tumefaction  of  these  folds,  or  the  production  of  a  false  membrane 
upon  their  surface  or  a  vegetaba  arising  from  coagulated  blood  ?  This  vegetaba 


THE    PURRING    VIBRATION. 


615 


I  have,  moreover,  observed  in  the  arteries  a  phenomenon  which 
I  consider  as  quite  identical,  although  presenting  occasionally 
some  slight  and  variable  differences.  The  purring  vibration  of 
the  heart  may  be  very  exactly  compared  with  the  thrill  which 
attends  the  murmur  of  satisfaction  expressed  by  the  cat  when 
stroked  by  the  hand.  We  may  also  convey  some  idea  of  it  by 
passing  a  rather  rough  brush  along  the  palm  of  the  hand  covered 
with  a  glove.  This  thrill  becomes  frequently  more  perceptible 
when  the  patient  speaks ;  no  doubt,  because  it  is  then  blended 
with  the  analogous  sensation  produced  by  the  resonance  of  the 
voice  within  the  chest.  This  tremor  or  vibration  is  almost 
always  confined  to  the  left  cardiac  region,  (and  the  hand  must  be 
applied  with  some  force  in  order  to  feel  it ;)  but  I  have  sometimes 
perceived  it  nearly  over  the  whole  anterior  part  of  the  chest,  and 
even  at  the  upper  part  of  the  sternum. 

The  thrill  of  the  arteries  presents  several  varieties.  Most 
commonly  it  is  very  like  that  just  described,  and  is  exactly  con- 
fined within  the  calibre  of  the  vessel.  In  this  case  the  thrill  is 
successively  renewed  like  the  pulse ;  it  is  more  perceptible  by 
means  of  a  moderate  than  a  very  slight  pressure,  but  diminishes 
under  a  strong  pressure.  Sometimes,  on  the  other  hand,  and 
particularly  when  seated  in  the  carotids,  the  thrill  is  much  more 
extended  than  the  diameter  of  the  artery,  and  seems  more  super- 
ficial ;  it  is  occasionally  perceptible  over  a  space  of  two  inches  in 
breadth  on  the  side  of  the  neck.  In  this  case  the  thrill  is  con- 
tinuous and  without  any  pulsative  momentum  ;  and  its  sphere 
seems  more  extended,  the  lighter  the  pressure  is  made  with  the 
finger.  The  arteries  in  which  this  phenomenon  is  most  com- 
monly observed,  are,  in  the  first  place  the  carotids,  and  then 
the  subclavian,  brachial,  and  crural ;  it  is   sometimes,  but  rarely, 

would  subsequently  decay,  and  the  blood  re-Iiqucfying,  would  return  to  the 
circulating  current.  I  lately  saw  a  young  female  who  had  long  been  subject  to 
divers  accidents  which  indicate  organic  disease  of  the  heart,  as  habitual  dys- 
pnoea,  palpitations,  slight  and  temporary  swellings  around  the  ankle  joints. 
She  was  suddenly  attacked  with  a  viol  ant  oppression,  and  palpitations,  far  sur- 
passing any  former  ones:  the  pulse  was  weak,  thread-like,  and  remarkably 
intermittent;  the  legs  and  thighs  suddenly  swelled,  and  by  applying  the  hand 
to  the  precordial  regions,  a  premissement  rutuire  very  distinct,  was  felt  at  each 
beat  of  the  heart:  at  the  same  time  there  was  neither  dull  sound  nor  pain  in 
this  region.  The  beating  of  the  heart  against  the  ear  was  strong;  it  was  irreg- 
ular and  intermittent  like  the  pulse  :  there  was  no  bellows  nor  rasp-sound,  only 
a  Btrong  metallic  clink,  particularly  discernible  towards  the  point  of  the  heart. 
About  fifteen  days  were  passed  in  this  condition  :  at  the  end  of  which  the 
premissement  culture  declined,  and  finally  ceased.  From  the  moment  of  its  de- 
cline, the  pulse  rose  and  was  no  longer  intermittent  :  the  metallic  clink  was  no 
longer  heard,  although  the  heart  continued  to  exert  a  great  power,  manifesting 
the  continuance  of  its  hypertrophy:  finally  all  marks  of  cedema  disappeared.. 
One  of  the  must  remarkable  circumstances  of  the  case  was  that  the  premisse- 
ment catairc  was  not  accompanied  by  any  sound,  yet  the  character  of  the  pulsa- 
tion added  to  the  vibratory  premissement  sensible  to  the  hand,  indicated  an 
•bstacle  at  the  aortic  orifice  of  the  heart. — .dndral. 


616  EXPLORATION    OF    THE    HEART. 

met  with  in  the  ascending  aorta  (that  is,  under  the  top  of  the 
sternum,)  and  even  in  the  abdominal  aorta.  It  is  not  found  very 
distinct  in  the  smaller  arteries,  for  instance,  the  radial.  How- 
ever, when  it  exists  in  the  heart  or  larger  arteries,  or  even  when 
the  simple  bellows-sound  merely  exists  in  these,  the  pulse  fre- 
quently presents  a  sort  of  epitome  of  the  purring  vibration,  a 
slight  thrill  which,  although  accompanying  the  diastole  of  the 
artery,  seems  independent  of  this. 

Corvisart  was  acquainted  with  this  character  of  the  pulse  (al- 
though he  has  not  noticed  the  thrill  of  the  larger  arteries,)  and 
considered  it  as  pointing  out  the  existence  of  the  same  phenome- 
non in  the  heart  in  a  greater  degree,  and  as  a  sign  of  ossification 
of  the  valves.*  This  state  of  the  pulse,  however,  is  by  no  means 
constant :  it  is  frequently  met  with,  as  I  have  said,  when  the 
purring  thrill  exists  no  where  else,  and  it  is  sometimes  wanting 
when  this  exists  in  the  cardiac  region.  In  every  case  where  I 
perceive  this  state  of  pulse,  I  remark  that  a  great  many  of  my 
pupils  cannot  distinguish  it ;  and  I  did  not  myself  perceive  it 
until  after  I  had  noticed  the  phenomenon  in  the  larger  arteries. 
It  is  extremely  uncommon  to  find  the  purring  thrill  in  the  heart 
or  in  an  artery,  unaccompanied  with  the  bellows-sound  ;  I  am 
even  doubtful  if  the  former  ever  existed  without  some  trace  of 
the  latter.  In  two  cases  only  I  have  observed  a  very  evident 
thrill  in  the  carotid,  with  a  bellows-sound  so  obscure  as  to  be 
doubtful ;  but  in  almost  every  case,  the  latter  phenomenon  exists 
at  the  same  time,  and  in  a  much  more  definite  and  striking  de- 
gree than  the  latter.  On  the  other  hand,  we  are  certain  that  the 
purring  thrill  is  not  identical  with  the  bellows-sound,  and  owing 
to  the  same  cause,  since  we  find  that  the  latter,  when  most  strik- 
ingly marked,  is  not  always  accompanied  by  the  former.  Very 
often  when  the  bellows-sound  is  diffused,  the  purring  thrill  is 
quite  confined  within  the  limits  of  the  artery,  and  vice  versa. 
Both  these  phenomena  are  frequently  attended  with  a  greater 
pulsation  than  usual ;  at  other  times,  the  reverse  obtains.  I  have 
often  found  the  pulsation  of  the  left  carotid  stronger  than  that 
of  the  right,  although  the  latter  alone  presented  the  phenomenon 
in  question. — Bloodletting  which  commonly  diminishes  the  in- 
tensity of  these  sounds,  at  other  times  modifies  them  in  a  singular 
manner.  I  have  thus  seen,  in  a  case  of  hemiplegia  unaccom- 
panied by  any  disease  of  the  heart,  inflammation  or  plethora,  the 
bellows-sound  become,  after  bloodletting,  much  less  in  the  cardiac 
region,  the  aorta,  and  left  carotid,  but  stronger  in  the  right  ca- 
rotid, as  did  also  the  purring  thrill. 

It  might  be  supposed  that  the  immediate  cause  of  a  pheno- 

*  Traite  des  Mai.  du  Cocur,  3e  ud.  p.  240. 


THK    1'UHHINU    VIBRATION. 


617 


menon  so  well  marked  as  the  purring  vibrations  of  the  heart  and 
arteries,  would  be  easily  discovered.  I  must,  however,  confess, 
that  all  my  endeavors  to  do  so  have  hitherto  failed.  Of  this 
much  I  am  well  assured,  that  it  does  not  depend  on  any  fixed 
organic  affection  ;  and  that  in  the  arteries,  more  especially,  it 
exists  in  a  striking  degree,  when  the  whole  of  their  tunics  are  in 
the  soundest  condition  as  to  color,  consistence,  thickness,  &c.  It 
seems  to  me  extremely  probable,  that  the  phenomenon  in  question 
depends  upon  a  peculiar  modification  of  the  nervous  influence.* 
A  man  debilitated  by  syphilis,  had  no  thrill  or  bellows-sound  in 
the  heart  or  arteries,  when  lying  down,  or  sitting  up  in  the  usual 
manner ;  but  if  he  raised  himself  in  bed,  supporting  himself  on 
his  elbow,  a  slight  but  very  distinct  purring  thrill  and  also  bel- 
lows-sound became  perceptible  over  the  extent  of  an  inch  square, 
a  little  above  the  right  clavicle  ;  and  both  these  disappeared  upon 
the  patient  assuming  the  sitting  posture. 

Sect.  III. — Of  the  Pulsation  of  the  Heart  perceived  at 
some  distance  from  the  Chest. 

It  had  long  been  believed,  but  rather  on  the  faith  of  traditional 
report   than  from  actual  observation,   that  the  pulsations  of  the 

*  The  purring  thrill  of  the  arteries  may,  like  the  hollows-sound,  he  merely  a 
vital  phenomenon,  or  dependent  on  some  modification  of  the  innervation;  but 
the  purring  thrill  of  the  heart  is,  like  the  sound  of  the  rasp,  with  which  it  con- 
stantly coincides,  the  effect  of  a  mechanical  obstacle  to  the  course  of  the  blood. 
At  least,  I  have  myself  never  observed  it,  except  in  persona  in  whom  a  post- 
mortem examination  discovered  cither  indurated  valves,  or  a  manifest  dispro- 
portion between  the  size  of  the  heart  and  the  calibre  of  the  large  arteries. 
Neither  do  I  recollect  to  have  found  this  phenomenon  intermittent,  a  thing  which 
ought  to  be  common,  if  it  were  merely  a  nervous  affection. — (M.  L.) 

J  agree?  with  Dr.  Mer.  Laennec  in  believing,  that  when  (i  the  thrill  exists  in 
the  region  of  the  heart,  it  is  identical  with  the  sound  of  the  saw,  rasp,  or  bel- 
lows :  the  difference  being  in  the  sense  which  perceives,  not  in  the  thing  per- 
ceived. If  we  could  always  say,  from  the  character  of  the  thrill,  with  which 
of  the  two  sounds  of  the  heart  it  is  identical,  it  would  be  more  valuable  as  a 
sign  than  it  is.  It  is  proper  to  observe  that  we  do  not  always  hear  any  of  the 
sounds  when  we  feel  the  vibration  ;  nor.  conversely,  do  we  always  feel  the  vi- 
bration  when  we  hear  the  sound.  This,  however,  is  not  any  proof  that  both  do 
not  spring  from  the  same  physical  cause.  The  cause  may  exist  in  a  degree  suf- 
ficient to  excite  one  sensation  and  not  the  other;  just  as  we  may  feel  or  see  the 
x  ibration  of  a  musical  string  after  the  ear  lias  ceased  to  hear  any  sound  from  it. 
It  is.  therefore,  we  conceive  without  good  grounds,  that  our  author  considers 
lire  separate  existence  of  these  phenomena  as  proofs  of  their  non-identity.  Dr. 
Hope  says  that,  although  resulting  from  the  same  causes  as  the  morbid  sounds, 
the  purring  tremor  or  thrill  requires,  cceteris  paribus,  a  stronger  current  for  its 
production  ;  for  which  reason  it  less  frequently  accompanies  the  passage  of  the 
blood  from  the  auricles  into  the  ventricles,  than  from  the  latter  into  their  res- 
pective arteries,  or  into  the  auricles  by  a  retrograde  movement.  Even  in  the 
latter  eases.  Dr.  Hope  adds,  it  is  seldom  strong  unless  the  ventricle  be  hypertro- 
phoiis.  or  the  circulation  hurried.  In  no  case  have  1  had  occasion  to  observe 
the  thrill  more  constantly  and  distinctly  than  in  the  thyroid  arteries  in  cases  of 
large  bronchocelc. —  Trans!. 

78 


^ 


618  EXPLORATION  OF  THE  HEART. 

heart  may  be  sometimes  heard  at  a  certain  distance  from  the 
patient.  Corvisart  informs  us,  that  he  had  observed  this  fact  but 
once,  and  only  then  on  placing  the  ear  very  near  the  chest.  Many 
years  since,  I  was  informed  by  several  patients,  that  they  were 
subject  to  palpitations  of  such  severity,  that  they  could  be  heard 
at  the  distance  of  several  paces :  and  one  of  these  patients,  as  well 
as  persons  of  credibility,  witnesses  of  the  fact,  assured  me  that, 
in  his  case,  the  palpitations  could  be  heard  in  the  chamber  ad- 
joining that  in  which  he  slept.  I  observed  this  phenomenon  for 
the  first  time  in  the  year  1823,  in  the  case  of  a  young  woman; 
and  having  since  then  paid  particular  attention  to  the  circum- 
stance, I  am  convinced  that  although  it  is  very  uncommon  to 
meet  with  it  in  so  great  a  degree  as  that  just  mentioned,  it  is  very 
common  to  find  it  in  a  less  degree,  such,  namely,  as  to  be  heard 
at  a  distance  of  from  two  to  ten  inches  from  the  chest.  Several 
of  my  colleagues,  to  whom  I  had  mentioned  the  fact,  have  likewise 
noticed  it  several  times  since ;  and  M.  Lerminier,  among  others, 
was  kind  enough  to  send  to  my  Clinic,  in  1824,  two  patients  in 
whom  it  was  perceptible  in  a  very  considerable  degree.  In  no 
case  have  I  myself  heard  the  pulsation  at  a  greater  distance  than 
a  foot  and  a  half  or  two  feet ;  but  we  can  readily  admit  the  pos- 
sibility of  this.  1  have  several  times  ascertained  from  the  perfect 
accordance  of  the  sound  with  the  pulse,  that  it  was  owing  to  the 
contraction  of  the  ventricles.  I  do  not  recollect  to  have  ever 
heard  it  produced  by  the  auricles.  Out  of  more  than  twenty 
subjects  in  whom  I  have  heard  the  pulsation  at  a  distance  of  from 
two  inches  to  two  feet, — three  or  four,  at  most,  were  affected  with 
organic  disease  of  the  heart.  All  the  rest  labored  under  palpi- 
tation of  a  purely  nervous  kind  :  and  several  were  only  so  affected 
after  quick  walking,  or  ascending  a  staircase.  In  all  of  them  the 
effect  was  temporary,  and  several,  after  a  certain  time,  regained 
perfect  health.  The  bellows-sound  and  purring  thrill  frequently 
exist,  in  a  slight  degree,  particularly  in  the  arteries,  in  such  cases. 
Never  having  had  an  opportunity  of  examining  the  body  of  any 
one  who  had  presented  this  phenomenon,  I  cannot  speak  with  any 
certainty  as  to  the  organic  cause  of  it ;  but  I  am  induced  to  eon- 
siderer  it  as  owing  to  the  presence  of  a  greater  or  less  quantity  of 
air  in  the   pericardium.*     The  ossification  of  some  external  part 

This  seems  a  very  gratuitous,  and  to  me  a  most  untenable  explanation  ;  and 
the  assertion  that  follows  it,  and  which  I  have  not  translated,  viz.  "  that  all 
sounds  produced  in  the  animal  body,  and  audible  by  the  naked  ear,  are  owing  to 
the  motion  of  substances  in  contact  with  air,"  is  still  more  extraordinary.  I 
have  myself  witnessed  the  fact  mentioned,  but  have  never  thought  of  attribu- 
ting it  to  any  other  causes  than  to  a  modification  of  those  by  which  we  are  ena- 
bled to  hear  the  sound,  in  all  cases,  by  means  of  the  stethoscope.  A  slight 
sound  is  perceived  through  a  good  conductor  (the  instrument) ;  a  more  intense 
one  may  be  heard  through  a  bad  conductor  (the  air) .—  Transl. 


PALPITATION    OF    THE    HEART. 


619 


of  the  heart,  may  also  give  rise  to  the  phenomenon  ;  but  I  have 
met  with  no  example  of  the  kind.* 


CHAPTER  VI. 

OF    PALPITATION    OF    THE    HEAI1T. 

By  palpitation  of  the  heart  is  meant,  in  the  common  language  of 
medicine,  every  beating  of  the  heart  which  is  sensible  and  unplea- 
sant to  the  individual,  and,  at  the  same  time,  more  frequent  than 
natural,  and  sometimes  unequal,  both  as  to  force  and  extent. 
When  this  affection  is  studied  by  the  aid  of  the  stethoscope,  we 
find  that  there  are  many  varieties  of  it,  all  of  which  appear  to 
have  merely  this  character  in  common,  that  the  individual  is  sen- 
sible of  the  heart's  action.  Frequently,  also,  the  patient  hears 
the  pulsations,  especially  when  in  the  horizontal  posture.  In  the 
upright  position,  the  contraction  of  the  ventricles  only  is  heard  ; 
while,  when  lying  on  the  side,  the  individual  is  sensible  of  a  pul- 
sation in  his  ear  double  that  of  the  pulse,  namely,  the  alternate 
contraction  of  both  the  ventricles  and  auricles.  I  have  nfton 
repeated  this  observation  on  myself,  in  states  of  wakefulness 
attended  by  slight  palpitation.  In  many  cases  there  is  merely 
an  increased  frequency  of  pulsation,  although  the  patient  ima- 
gines, from  his  sensations,  that  there  is  also  great  increase  of  force. 

*  It  is  very  certain  that  the  beating  of  the  heart  may  sometimes  be  heard  at 
a  distance  from  the  chest :  I  have  known  repeated  instances  in  persons  with 
organic  disease  of  the  heart,  and  others  with  simple  nervous  palpitations.  The 
most  remarkable  case  was  that  of  a  young  woman  with  symptoms  of  hysteria, 
who  at  irregular  intervals,  fell  senseless  into  swooning  fits.  During  these  fits, 
which  sometimes  lasted  several  hours,  the  circulating  system  was  affected  in  the 
following  manner.  The  pulse  rather  small,  but  so  rapid  that  the  pulsations 
could  hardly  be  counted  ;  the  skin  cold,  and  the  face  purple;  the  heart  beat 
with  a  violence  that  might  be  heard  at  the  distance  of  several  feet.  During  five 
or  six  days  she  breathed  with  difficulty  and  suffered  some  palpitations,  after 
which,  order  was  restored. 

Laennec's  explanation  of  these  sounds  of  the  heart  heard  at  a  distance,  appears 
not  to  be  sustained  by  fact.  It  is  a  mere  supposition  of  his,  that  gases  in  the 
cavities  of  the  heart,  produce  this  phenomenon.  The  supposed  analogical  facts 
cited  by  him  in  support  of  his  opinion,  have  no  real  analogy.  Thus,  what  re- 
lation have  the  borborygmi  developed  in  the  intestines  filled  with  air  and  liquids, 
to  the  sounds  of  the  heart?  The  two  facts  cannot  be  connected  unless  we  hear 
in  the  heart  sounds  similar  to  those  caused  by  the  displacement  of  gas  It  is  yet 
to  be  proved  also,  that  the  articulations  are  frequently  filled  with  gas  in  conse- 
quence of  rheumatism  :  such  an  opinion  is  mere  hypothesis,  and  there  is  quite  a 
different  method  of  explaining  the  crepitation  heard  in  inflamed  articulations, 
and  the  crackling  of  the  fingers  which  some  indiviauals  can  produco  at  pleasure. 
These  are  only  frictions  between  the  surfaces  of  the  joints :  the  same  sound  is 
heard  in  the  pericardium  when  the  false  membranes  rub  together  on  its  inner 
surface. — Andral. 


620  EXPLORATION    OF    THE    HEART. 

This  species  of  palpitation  is  most  common  in  dilatation  of  the 
ventricles,  and  lasts  the  longest  of  any.  I  have  known  it  con- 
tinue eight  days  ;  the  pulse  remaining,  through  the  whole  of  this 
time,  extremely  small  and  weak,  and  between  160  and  180. 

Another  variety  consists  in  an  increase  both  of  the  frequency 
and  force  of  pulsation.  This  is  what  arises  in  healthy  persons 
from  great  exertion  or  from  moral  causes.  It  also  accompanies 
slight  degrees  of  hypertrophy  ;  in  which  case  the  impulse  of  the 
ventricles  becomes  greater  than  natural.  These  two  kinds  of 
palpitation  cannot  be  distinguished  except  by  the  statements  of 
the  patient,  and  the  acceleration  of  the  circulation.  The  sound 
and  sphere  of  the  heart's  pulsations  are  almost  always  increased 
during  palpitation  :  on  which  account  we  must  never  draw  any 
conclusions  from  the  exploration  of  the  circulation  by  the  stetho- 
scope, unless  this  has  been  made  during  a  state  of  the  most  per- 
fect quietude  ; — that  is  to  say, — not  till  after  a  sufficient  rest,  if 
the  person  has  been  exercising  himself ;  or  during  the  most  per- 
fect quietude,  if  there  already  exists  disease  of  the  heart.* 

In  simple  hypertrophy  in  a  high  degree,  during  palpitation  the 
ventricles  are  found  to  contract  with  great  force,  and  seem  to 
elevate  the  thoracic  parietes  in  an  extent  and  to  a  height  much 
greater  than  natural.  The  sound,  however,  produced  by  their 
contraction  is  much  duller  and  more  indistinct  than  usual ;  and 
this  circumstance,  together  with  the  increased  frequency  of  pul- 
sation, frequently  prevents  the  contractions  of  the  auricle  from 
being  distinguished.  The  extent  of  the  thorax  over  which  the 
pulsation  is  perceptible  is  not  increased ;  ana*  notwithstanding 
the  increase  of  the  heart's  power  to  double  or  triple  its  ordinary 
force,  the  pulse  is,  almost  always,  two  or  three  times  more  feeble 
and  smaller  than  in  the  natural  condition  of  the  circulation. 
When  the  palpitation  lasts  several  successive  days,  and  there 
supervenes  much  oppression  on  the  chest,  with  livid  countenance 
and  cold  extremities,  the  pulse  becomes  almost  imperceptible, 
the  action  of  the  heart,  excessively  frequent,  loses  its  impulse,  bc- 

*  On  the  contrary,  there  are  cases  in  which  the  heart  in  a  state  of  hypertro- 
phy, continues  to  beat  with  remarkable  force  to  the  last  moment  of  life,  and 
even  when  the  skin  has  grown  cold,  and  the  pulse  is  like  a  thread.  1  have 
particularly  marked  this  in  persons  in  whom  the  aortic  orifice  -had  contracted, 
and  for  a  long  time  had  greatly  obstructed  the  passage  of  the  blood.  In  these 
cases  when  the  pulse  fails  or  becomes  very  feeble, and  the  extremities  grow 
cold,  the  continuance  of  a  strong  impulsion  at  the  heart  may  authorize  blood- 
letting which  is  often  very  successful,,  I  ha\  e  seen  cases  of  this  sort  where  tin- 
blood  had  hardly  started  from  the  vein  before  the  pulse  re-appeared,  tin  skin 
grew  warm,  the  asphyxia  ceased,  ami  al  the  same  time  the  heating  of  the  heart 
became  less  violent.  It  would  seem  that  in  these  cases  the  heart  is  struggling 
to  expel  from  its  cavities  the  blood  which  obstructs  them  :  hut  the  aortic  orifice 
opposes  an  insuperable  obstacle,  and  the  heart  grows  more  and  more  disturbed 
by  the  blood  from  the  veins,  unless  we  diminish  artificially  and  without  delay, 
the  general  mass  of  blood. — Jlndral. 


IRREGULARITIES    IN    PULSATIONS.  621 

comes  sometimes  more  sonorous,  and  at  length  indistinct  or  un- 
distinguisliable  for  some  days  before  death.  In  hypertrophy  with 
dilatation,  the  impulse,  sound,  and  extent  of  the  heart's  action, 
are  usually  equally  increased,  during  palpitation  ;  and  it  is  more 
especially  in  this  case,  and  when  both  affections  exist  in  a  mode- 
rate degree,  that  we  find  the  pulsations  of  the  heart  resembling, 
as  formerly  mentioned,  the  blow  of  the  mallet. 


CHAPTER  VII. 

OF    IRREGULARITIES    IN    THE    PULSATIONS    OF    THE     HEART. 

Irregularities  in  the  pulsations  of  the  heart  may  exist  without 
palpitation.  In  old  persons  this  is  often  met  with  without  any 
perceptible  alteration  of  the  general  health.  The  irregularity 
which  occurs  in  palpitation  consists  usually  in  mere  variations  in 
the  frequency  of  the  heart's  pulsation.  Sometimes  this  variation 
is  almost  constantly  recurring ;  at  other  times  it  is  at  long  in- 
tervals, and  consists  only  of  a  few  contractions  longer  or  shorter 
than  the  rest.  Sometimes,  amid  a  series  of  pulsations,  very  un- 
equal among  themselves,  a  single  one  will  occur  one-half  shorter 
than  the  rest.  This  gives  rise  to  something  like  an  intermission  ; 
and  it  completely  resembles  this,  if  the  pulsation  is  weaker  as  well 
as  shorter  than  the  others.  The  variations  of  frequency  most 
commonly  implicate,  as  in  this  case,  complete  pulsations  ;  but 
they  sometimes  are  owing  to  the  mere  increase  or  diminution  of 
the  period  of  contraction  of  the  ventricles.  These  irregularities 
as  to  frequency,  take  place  most  usually  in  persons  affected  with 
dilatation  of  the  heart.  It  is  during  the  existence  of  palpitation 
more  especially,  in  the  case  of  hypertrophy,  that  we  observe  those 
prolonged  contractions  of  the  ventricles,  which  completely  mask 
the  sound  of  the  auricles.  No  doubt  these  contract :  but  owing 
to  the  want  of  any  visible  interval  between  the  contractions  of  the 
ventricles,  they  are  not  perceived.  It  sometimes,  though  very 
rarely,  happens  during  palpitation,  that  each  contraction  of  the 
ventricles  is  followed  by  several  successive  contractions  of  the 
auricles,  so  quick  as  only  to  equal  in  point  of  time  one  ordinary 
contraction.  In  this  sort  of  palpitation,  I  have  sometimes  reck- 
oned two  pulsations  of  the  auricles  for  one  of  the  ventricles  • 
sometimes  four :  but  most  commonly  three.  In  one  case  of 
hypertrophy  of  the  left  ventricle,  I  saw  this  species  of  irregula- 
rity continue  for  several  days  without  any  variation.  Sometimes 
after  a  long  succession  of  regular  contractions  we  observe  only 


622  EXPLORATION  OF  THE  HEART. 

one  or  two  of  the  kind  just  mentioned.  Neither  this  nor  the  pre- 
ceding variety  occasions  any  sensible  alteration  in  the  pulse ;  I 
have  only  observed  them  in  cases  of  hypertrophy. 

The  above  are  the  principal  kinds  of  palpitation  with  irregular 
action  of  the  heart ;  but  there  are  many  others,  although  I  have 
not  yet  examined  them  with  the  stethoscope.  Of  this  kind,  in 
particular,  is  one  which  sometimes  is  observed  during  palpitation 
from  hypertrophy ;  in  this  there  is  a  suspension  of  the  pulse, 
during  which  the  artery  remains  full  and  tense,  and  resists 
strongly  the  compressing  finger.  This  variety  is  observed  most 
frequently,  or  almost  constantly  during  fits  of  coughing  ;  at  which 
times  the  heart  cannot  be  examined  on  account  of  the  agitation 
of  the  walls  of  the  chest. 


CHAPTER  VIII. 

OF    INTERMISSIONS    IN   THE  PULSATIONS    OF    THE    HEART. 

By  intermission  we  usually  understand  a  sudden  and  momentary 
suspension  of  the  pulse,  during  which  the  artery  is  no  longer 
perceptible  beneath  the  finger.  The  duration  of  the  intermission 
is  very  variable,  and  may  serve  to  divide  this  affection  into  well- 
marked  varieties.  Sometimes  the  intermission  is  shorter  than 
one  arterial  pulsation  ;  sometimes  it  is  equal ;  and  sometimes  it  is 
longer.  We  can  distinguish  two  kinds  of  intermission, — the  one 
real,  consisting  in  an  actual  suspension  of  the  heart's  contrac- 
tions ;  the  other  false,  depending  on  contractions  so  feeble  as  to 
be  imperceptible,  or  almost  imperceptible,  to  the  touch,  in  the 
arteries.  Intermissions  of  the  first  kind  are  most  common  :  they 
are  frequent  in  old  age,  even  during  health  ;  and  they  show  them- 
selves in  such  as  are  not  usually  subject  to  them,  during  very 
slight  indispositions.  In  middle  age  they  are  only  observed  in 
certain  diseased  states  of  the  heart,  particularly  hypertrophy  of 
the  ventricles,  and  during  palpitation :  they  would  perhaps  be 
more  properly  named  retardations  or  stoppages  of  the  pulse.  By 
means  of  the  stethoscope  we  ascertain  that  this  species  of  inter- 
mission always  succeeds  the  contraction  of  the  auricles.  It, 
therefore,  only  differs  from  the  natural  quiescence  after  this  con- 
traction, in  the  irregularity  of  its  recurrence. 

The  duration  and  recurrence  of  this  species  of  suspension  of 
the  heart's  action  are  very  variable.  Frequently  during  a  close 
succession  of  similar  intermissions,  some  are  equal  to  a  complete 
contraction  of  the  heart,  others  are  only  one-half,  a  third,  or  fourth 


INTERMISSION. 


623 


as  long,  and  some  are  barely  perceptible.  Their  recurrence  is 
equally  uncertain  ; — they  being  sometimes  perceived  after  each 
pulsation,  or  nearly  so,  and  then  not  until  after  ten,  twenty,  or 
even  one  hundred  pulsations.  If,  in  our  examinations,  we  con- 
tent ourselves  with  feeling  the  pulse,  without  applying  the  stetho- 
scope, we  shall  of  necessity,  confound  this  true  intermission  with 
the  false  one  formerly  mentioned,  produced  by  variations  in  the 
duration  and  force  of  the  heart's  pulsation.  By  the  stethoscope, 
however,  we  can  very  readily  distinguish  it  from  the  retarda- 
tions. It  is  not  so  easy  to  draw  the  line  between  this  and  the 
repeated  contractions  of  the  auricles  also  mentioned  before.  The 
feebler,  shorter,  and  quicker  pulsations  completely  resemble  the 
auricular  contraction  ;  and  if,  after  a  distinct  contraction  of  the 
ventricles,  distinguished  by  its  impulse  and  its  dull  and  pro- 
longed sound,  there  supervene  three  feebler  contractions  attended 
by  a  much  clearer  sound,  we  cannot  be  certain  whether  these  are 
owing  to  a  threefold  contraction  of  the  auricle,  or  whether  the 
first  is  the  contraction  of  the  auricle,  and  the  two  last  are  a  re- 
gular ventricular  and  auricular  contraction.  Should  there  exist 
two  or  four  of  these  contractions,  there  will  be  no  uncertainty. 

The  last  species  of  intermission  is  that  which  consists  in  the 
absence  of  one  complete  pulsation,  recurring  sometimes  with  an 
exact  periodicity,  after  longer  or  shorter  intervals,  the  pulse  being 
in  other  respects  regular.  This  pulse  constitutes,  according  to 
Solano,  the  precursor  of  a  critical  diarrhoea.  This  peculiarity 
of  the  circulation  is  by  no  means  rare ;  I  have  observed  it  fre- 
quently in  some  epidemics,  but  not  at  all  in  others,  owing  no 
doubt  to  the  particular  constitution  that  prevailed.  This  kind 
of  intermission  corresponds  more  frequently  to  a  contraction  of 
the  ventricles,*  much  weaker  than  the  rest,  than  to  a  real  inter- 

*  The  intermissions  of  the  pulse  may  be  occasioned  altogether  by  nervous 
causes  ;  many  instances  of  the  kind  may  be  seen  in  acute  diseases.  Yet  when 
these  intermissions  are  of  long  continuance  without  any  other  disturbance  of 
the  nervous  system,  there  is  a  great  probability  that  they  are  caused  by  a  con- 
traction of  the  aortic  orifice,  an  alteration  which  may  be  so  little  advanced  as 
not  to  give  any  other  symptom  of  its  existence — no  palpitation,  dyspnoea, 
oedema,  nor  lesion  of  the  heart  discoverable  by  auscultation  or  percussion. 
These  intermissions  may  be  constant  or  occur  only  at  intervals,  and  under  the 
influence  of  known  causes.  I  knew  a  man  of  about  sixty  who  could  cause 
these  intermissions  at  will,  by  going  up  stairs  a  little  quicker  than  common;  he- 
had  no  other  symptom  of  disease  of  the  heart.  I  have  seen  other  individuals- 
who  were  likewise  in  good  health,  yet  whose  pulse  became  intermittent  under 
the  influence  of  physical  or  moral  causes  which  quickened  the  circulation.  In 
other  cases  the  intermission  arises  spontaneously.  Some  of  these  patients  feel 
at  each  intermission  of  the  pulse  very  distinctly,  a  stop  in  the  contraction  of  the 
heart ;  this  sensation  is  in  some  cases  very  painful,  attended  with  great  anxiety,. 
and  sometimes  followed  by  palpitations,  after  which  the  heart  returns  to  its  nat- 
ural state  of  action. 

In  other  individuals  the  habitual  intermission  of  the  pulse  is  attended  with, 
symptoms  of  disease  of  the  heart;  but  on  auscultation,  none  of  the  sounds 
which  commonly  denote  a  contraction  of  the  aortic  orifice  can  be  heard.     Yet 


624  EXPLORATION  OF  THE  HEART. 

ruption  of  their  action ;  and,  indeed,  in  such  cases,  we  often 
perceive  an  extremely  feeble  pulsation  in  place  of  a  total  inter- 
mission.* I  have  not  hitherto  had  an  opportunity  of  examining 
the  state  of  the  heart  in  that  species  of  intermission,  which  is  at- 
tended by  a  continued  state  of  fullness  of  the  artery.  We  ought 
to  consider  it,  from  analogy,  as  taking  place  immediately  after 
the  contraction  of  the  ventricles ;  and  that  their  contraction  con- 
tinues during  the  period  of  their  intermission. 

Many  of  the  facts  adduced  in  the  foregoing  analysis  of  the 
pulsation  of  the  heart,  suffice  to  prove,  that  the  application  of 
the  hand  to  the  cardiac  region,  and  feeling  the  pulse,  are  very 
inadequate  guides  to  the  real  state  of  the  circulation.  The  exa- 
mination of  the  pulse,  in  particular,  at  least  as  it  has  been  hith- 
erto done  without  any  corresponding  exploration  of  the  heart, 
is  as  often  calculated  to  mislead  as  to  supply  us  with  useful  indi- 
cations ;  and  notwithstanding  the  ingenious  and  subtile  researches 
of  Galen,  Solano,  Bordeu,  and  Fouquet,  and  the  physicians  of 
China,  I  conceive  that  every  candid  practitioner  must  have  often 
said  with  Celsus — "Venis  ....  Maxim e  credimus  fallacissemse  rei." 
I  am  far  from  wishing  to  call  in  question  the  accuracy  of  all  the 
observations  of  the  above-named  authors ;  on  the  contrary,  I 
admit  that  some  of  the  most  curious  are,  in  a  general  point  of 
view,  well  founded ;  for  instance,  I  think  we  often  observe  the 
dicrote  pulse  precede  or  accompany  epistaxis,  the  undulating 
pulse  attend  sweating,  the  intermitting  pulse  accompanying  di- 
arrhoea, and  believe  that  we  may  admit  (with  pretty  numerous 
exceptions  however)  the  distinction  of  pulses  into  superior  and 
inferior.  But  admitting  the  utility  of  the  pulse  in  these  respects, 
it  is  yet  more  evident,  that  it  frequently  supplies  us  with  no  in- 
dications at  all,  or  with  such  as  are  deceitful  in  still  more  impor- 

the  absence  of  these  sounds  does  not  prove  that  there  is  no  such  contraction  ; 
we  can  only  infer  from  it  that  the  lesion,  in  consequence  <>f  its  locality,  causes 
no  anormal  sound.  Thus  in  a  woman  who  died  at  La  Charite  with  an  intermit- 
tent pulse,  hut  no  sound  of  friction  in  the  precordial  regions.  1  found  the  three 
valves  of  the  aorta  to  contain  long  and  cartilaginous  points  at  their  bases  ;  in 
all  other  parts  they  were  sound:  the  coats  of  the  left  ventricle  were  inflamed 
and  its  cavity  somewhat  dilated.  Nothing  had  been  remarked  during  life,  ex- 
cept irregular  beatings  which  struck  the  ear  very  strongly. 

Intermissions  occasioned  by  a  contraction  of  the  aortic  orifice  may  be  cured 
by  bleeding  and  quiet  with  proper  food ;  but  the  smallest  excitement  given  to 
the  circulation  will  bring  them  on  again. — Jiiulrul. 

In  certain  cases  of  diseased  heart  I  have  observed  this  species  of  intermis- 
sion under  a  form  which  was  sometimes  productive  of  curious  results.  Every 
second  pulsation  was  so  feeble  as  to  be  altogether  or  almost  entirely  impercep- 
tible. In  the  former  case,  the  pulse  appeared  to  be  quite  regular  and  slow  ;  but, 
while  in  the  act  of  feeling  it,  the  intermediate  or  latent  pulsation  (if  I  may  use 
the  expression)  became  suddenly  distinct,  and  the  pulse  was  instantly  tloiihlul. 
In  this  manner  I  have  known  the  same  patient  with  a  regular  pulse  at  fifty  or 
sixty,  and  a  regular  pulse  at  one  hundred  or  one  hundred  and  twenty,  within  the 
space  of  three  minutes. —  TrunsL 


INTERMISSION. 


625 


tant  respects,— for  instance,  in  relation  to  bloodletting,  to  the 
prognosis  in  all  diseases,  and  to  the  diagnosis  in  several.  What 
Celsus  says  of  it  in  regard  to  fevers,  is  s-till  more  applicable  in 
diseases  of  the  lungs  and  heart.  We  have  seen,  that,  in  pneu- 
monia and  pleurisy,  the  absence  of  fever  and  a  perfectly  natural 
state  of  the  pulse,  frequently  accompany  a  severe,  extensive,  and 
incurable  disease.  In  phthisis,  the  hectic  fever  is  sometimes 
suspended  during  whole  months.  In  diseases  of  the  heart,  the 
pulse  is  often  feeble,  sometimes  even  almost  imperceptible,  al- 
though the  heart's  contraction,  that  especially  of  the  left  ven- 
tricle, is  much  more  energetic  than  natural.  In  apoplexy,  on  the 
contrary,  we  often  meet  with  a  very  strong  pulse  in  persons  in 
whom  the  impulse  of  the  heart  is  scarcely  observable.  These 
two  opposite  facts  may  easily  be  verified  by  the  use  of  the  steth- 
oscope: I  have  myself  done  so,  daily,  during  the  last  ten  years. 
They  appear  quite  inexplicable,  unless  we  admit  the  arteries  to 
possess  a  power  of  action  independent  of  that  of  the  heart. 

It  would  seem  to  be  proved,  also,  by  many  other  facts,  that  the 
different  systems  subservient  to  the  circulation,  although  neces- 
sarily and  reciprocally  dependent,  have  still,  in  other  respects,  a 
particular  or  individual  existence,  which,  in  certain  states  of  dis- 
ease, and  in  certain  individuals,  is  more  marked  and  isolated  than 
in  ordinary  cases  and  circumstances.  This  view  of  the  case  is 
supported  by  the  observations  of  practitioners,  in  all  ages,  of  the 
different  effects  of  bleeding,  according  as  it  is  general  or  local, 
venous  or  arterial,  depletive  or  derivative.  The  same  is  shown 
by  the  great  benefit  of  a  natural  haemorrhage  of  a  few  ounces 
only,  and  the  inefficacy  of  copious  venesection  in  the  same  case ; 
and  by  the  trifling  degree  of  exhaustion  produced  sometimes  by 
very  profuse  haemorrhage,  compared  with  the  great  collapse  oc- 
casioned by  the  bleeding  of  a  few  leeches  in  the  same  person.  I 
am  acquainted  with  a  man,  who  has  been  repeatedly  bled  to  the 
extent  of  eight  or  twelve  ounces,  without  being  thereby  at  all  de- 
bilitated, but  in  whom  the  application  of  only  two  leeches  to  the 
anus,  has,  on  two  different  occasions,  produced  an  extreme  de- 
gree of  muscular  debility.  These  facts  prove,  I  think,  that  the 
capillary  circulation  is  in  some  sort  independent  of  the  general. 
The  influence  of  the  latter  on  the  former  seems  very  inconsider- 
able indeed  in  certain  haemorrhages  from  the  uterus,  bowels,  nose 
or  lungs,  which  are  found  to  be  very  little  affected  by  the  most 
copious  venesection.  The  mere  state  of  the  pulse,  then,  is  far 
from  indicating  the  state  of  the  circulation  in  general :  it  does 
not  even  certainly  indicate  its  condition  in  the  whole  heart,  as  it 
merely  corresponds  with  the  contraction  of  the  left  ventricle, 
which  may  be  regular  at  the  time  when  that  of  the  auricles  and 
right  ventricle  is  irregular.  In  like  manner,  the  state  of  the 
79 


626  EXPLORATION  OF  THE  HEART. 

pulse  fails  to  be  a  sure  guide  as  to  the  expediency  of  bloodlet- 
ting. Every  one  knows  that  in  certain  cases,  for  instance,  in  apo- 
plexy, pneumonia,  pleurisy,  and  inflammatory  affections  of  the 
abdomen,  the  weakness  and  smallness  of  the  pulse  do  not  always 
contra-indicate  venesection  ;  on  the  contrary,  that  the  artery,  in 
such  cases,  frequently  recovers  its  force  and  fullness  after  the  loss 
of  blood.  The  recognition  of  this  kind  of  pulse  (fictitie  debilis) 
isjone  of  the  most  important  and  difficult  points  in  the  treatment 
of  acute  diseases,  as  an  error  in  respect  of  it  may  be  fatal.  In 
cases  of  this  sort  the  stethoscope  affords  a  rule  much  surer  than 
the  pulse.  Whenever  the  contraction  of  the  ventricles  is  energetic, 
we  may  bleed  without  fear, — the  pulse  will  rise  ;  but  if  the  con- 
tractions of  the  heart  are  feeble,  although  the  pulse  still  retains  a 
certain  degree  of  strength,  we  must  be  cautious  respecting  the  em- 
ployment of  venesection.  When  the  pulse  is  yery  strong, and  the 
contraction  of  the  heart  moderately  strong,  (as  is  frequently  the 
case  in  apoplexy,)  we  may  still  bleed  with  advantage  as  long  as 
there  is  not  a  marked  diminution  in  the  sound  and  impulse  of  the 
heart.  But  when  both  the  pulse  and  the  heart  are  feeble,  we  must 
not  open  a  vein,  whatever  be  the  name  or  seat  of  the  disease,  as 
such  practice  must  infallibly  destroy  the  few  resources  still  left  to 
nature.  The  most  we  can  do  in  such  a  case,  if  there  be  any  local 
congestion,  is,  by  the  application  of  a  few  leeches,  to  try  if  the 
patient  can  bear  the  subtraction  of  blood  from  the  capillaries. 
The  certainty  and  facility  with  which  the  cylinder  indicates  the 
propriety  of  bloodletting  in  such  cases  as  those  above  mentioned, 
(which  have  hitherto  been  considered  among  the  most  difficult 
in  practical  medicine,)  appears  to  me  to  be  one  of  the  greatest 
advantages  to  be  derived  from  the  employment  of  this  instrument. 
It  is  certainly  of  the  most  general  application,  as  it  refers  to  the 
employment  of  one  of  our  therapeutic  measures,  which  is  the  most 
useful  or  the  most  injurious  of  any,  and  which  may  be  had  re- 
course to  in  almost  all  diseases.* 


*  Laennec  is  doubtless  right  as  to  the  importance  of  auscultation  in  diseases 
of  the  heart ;  he  is  correct  also  in  asserting  that  there  is  often  no  connexion  be- 
tween the  strength  of  the  arterial  pulsations  and  that  of  the  heart :  but  ought 
we  to  infer  from  this  that  the  arteries  in  their  dilatation  are  animated  by  a  force 
of  their  own,  independent  of  the  heart?  I  think  not.  Such  a  power  cannot  be 
claimed  except  for  the  capillary  vessels.  In  the  most  common  and  plainest 
cases  of  this  sort,  where  there  is  a  disagreement  between  the  pulse  and  the 
heart,  this  last  organ  maintains  all  the  force  of  its  contractions,  and  the  artery 
becomes  enfeebled.  Now  the  anormal  diminution  of  the  pulse  in  such  a  case, 
depends  always  on  the  pathological  state  of  the  heart ;  and  this  diminution  fol- 
lows as  a  necessary  consequence  either  of  a  contraction  of  the  aortic  orifice,  or 
a  diminution  of  the  cavity  of  the  left  ventricle  (even  where  there  is  a  hypertro- 
phy of  the  coats)  or  of  an  extreme  enlargement  of  this  cavity.  As  to  the  op- 
posite case  where  the  pulse  continues  strong  while  the  contractions  of  (be  hearl 
become  feeble,  it  is  infinitely  more  race  than  the  preceding;  and  1  have  strong 
doubts   whether  it  has  often    occurred  even   in  apoplexy,   which  according  to 


INTERMISSION. 


627 


After  what  has  been  said,  and  after  its  general  uncertainty 
avowed  by  the  most  experienced  practitioners,  it  may  seem  sur- 
prising that  the  practice  of  feeling  the  pulse  has  been  so  gene- 
rally followed  in  all  ages.  The  reason  of  the  practice  is,  how- 
ever, sufficiently  obvious :  it  is  of  easy  performance,  and  gives 
little  inconvenience  either  to  the  physician  or  patient ;  the  cle- 
verest, it  is  true,  can  derive  from  it  but  a  few  indications  and 
uncertain  conjectures ;  but  the  most  ignorant  can,  without  ex- 
posing themselves,  deduce  from  it  all  sorts  of  indications.  Its 
very  uncertainty  gives  it  a  preference  with  persons  of  inferior 
qualifications,  over  means  quite  certain  in  their  nature,  and 
which  enable  the  non-professional  observer  to  judge  of  the  skill 
of  the  physician  by  the  correctness  of  his  diagnosis  and  prognosis. 
This  last  reason,  more  than  any  other,  leads  one  to  believe,  that 
long  after  the  utility  of  mediate  auscultation  shall  have  been  unan- 
imously admitted  by  the  better  informed  members  of  the  profes- 
sion, many  practitioners  will  still  be  found  to  neglect  or  even  to 
disdain  it,  (as  they  now  do  percussion.)  who  will,  nevertheless, 
think  their  time  not  at  all  mispent  in  feeling  the  pulse  of  an  hypo- 
chondriac, or  in  examining,  day  after  day,  the  fecal  excretions  of 
a  peripneumonic  patient. 

The  facts  above  stated  relative  to  the  discordance  (often  very 
great)  existing  between  the  pulsation  of  the  heart  and  of  the 
arteries, — more  especially  as  to  strength,  are  contrary  to  the  more 
general  opinion  of  modern  physiologists,  who  consider  the  action 
of  the  arteries  as  entirely  dependent  on  that  of  the  heart.  Bichat 
himself  has  fallen  into  this  error.  "  To  every  species  of  action 
of  the  heart  (he  says)  there  corresponds  a  particular  kind  of 
pulse.  I  am  astonished  that  the  authors  who  have  so  much  dif- 
fered on  this  point,  have  never  thought  of  having  recourse  to 
experiments  to  settle  the  question.  No  doubt  there  are  many 
modifications  of  the  pulse  which  would  not  be  found  to  corres- 
pond with  any  visible  modification  of  the  movements  of  the 
heart ;  but  the  frequent  and  slow  pulse,  the  strong  and  weak, 
the  intermitting,  undulating,  &c.  are  at  once  understood  in  laying 
bare  the  heart  and  placing-the  finger  on  the  artery  at  the  same 
time.  In  this  case  we  constantly  observe  that  for  every  modi- 
fication of  the  arterial  pulsation  there  is  a  corresponding  modi- 
fication of  the  pulsation  of  the  heart ; — which  would  not  be  the 
case,  if  the  pulse  depended  on  a  vital  contraction  of  the  arteries."* 
T  am  not  prepared  to  say  how  far  we  can  compare  the  visible 
pulsations  of  the  heart  to  the  felt  pulsations  of  the  arteries, — a 
comparison  the  less  to  be  depended  on,  seeing  it  can  only  be  made 

Laennec  is  the  disease  in  which  the  disagreement  between  the  pulsation  of  the 
heart  and  that  of  the  arteries  has  been  most  often  observed. — Andral. 
*  Anat.  Gen.  t.  ii.  p.  136.  Ed.  de  Beclard. 


628  EXPLORATION    OF    THE    HEART. 

on  an  animal  expiring  in  torture ;  but  I  am  well  assured  that 
we  shall  soon  be  convinced  of  the  truth  of  the  opposite  opinion, 
on  examining,  comparatively,  the  pulse  and  the  heart  in  certain 
diseases,  particularly  apoplexy  and  affections  of  the  heart. 
What  was  said  of  the  bellows-sound  and  purring  thrill  of  the 
heart  and  arteries,  goes  also  to  the  corroboration  of  the  same 
opinion.* 

In  bringing  to  a  conclusion  this  analysis  of  the  heart's  con- 
tractions, in  health  and  disease,  I  ought  to  state,  that  the  explo- 
ration of  this  organ  is  the  case  in  which  immediate,  compared 
with  mediate  auscultation,  would  be  least  defective  ;  were  it  not, 
for  reasons  formerly  mentioned,  nearly  impracticable  in  many 
cases.  Its  principal  inconveniencies  arc, — the  impossibility  of 
closely  applying  the  ear  at  the  lower  part  of  the  sternum  in  many 
eases  :  the  perception  of  the  action  of  both  sides  of  the  heart  at 
the  same  time ;  the  conjunction  of  the  sound  of  respiration  or  of 
those  depending  on  the  presence  of  gas  in  the  stomach,  with  the 
sound  of  the  heart ;  and,  sometimes,  the  much  too  great  intensity 
of  the  impulse  and  sound  of  the  heart,  when  perceived  over  too 
large  a  surface, — a  circumstance  which  prevents  our  being  able 
to  analyze  readily  the  motion  of  its  several  parts. 

*  The  argument  here  derived  from  auscultation,  in  favor  of  the  independent 
powers  of  the  capillaries,  is  an  important  addition  to  those  formerly  advanced  on 
this  side  of  the  question.  For  a  complete  view  of  the  evidence  on  both  sides.  1 
refer  the  reader  to  Dr.  Bostock's  admirable  System  of  Physiology,  vol.  i.  p.  381 , 
and  to  the  works  of  Drs.  Parry  (sen.  and  jun.),  Philip,  Hastings,  Thomson, 
Young,  Kerr,  Carson,  Hunter,  C.  Bell,  &c. —  Transl. 


BOOK  SECOND. 

OF  DISEASES  OF  THE  HEART. 


CHAPTER   I. 

OF    DISEASES    OF    THE    HEART    IN    GENERAL. 

Sect.  I. — Of  the  Symptoms  common  to  all  Diseases  of  the  Heart. 

It  will  appear  from  the  analysis  in  the  preceding  Book,  that  the 
employment  of  the  stethoscope  supplies  us  with  signs  more  pre- 
cise and  more  fitted  for  enabling  us  to  distinguish  the  principal 
diseases  of  the  heart,  than  those  which  had  been  previously 
known.  On  this  account  we  need  insist  the  less  upon  the  general 
and  local  symptoms,  by  which  it  had  been  previously  sought  to 
recognize  these  diseases.  In  the  present  section  I  shall  confine 
myself  to  the  notice  of  such  only  as  accompany  the  greater  num- 
ber of  these  affections  when  they  have  reached  a  certain  degree 
of  severity. 

The  severest  and  most  common  diseases  of  the  heart  are — 
dilatation  of  the  ventricles,  thickening  of  the  walls  of  these,  or 
the  re-union  of  both  affections.  Most  frequently  a  single  ven- 
tricle is  affected ;  sometimes  both  are  so  in  a  similar,  or  in  an 
opposite  manner,  as  in  the  common  case  of  dilatation  of  the  right 
ventricle  with  hypertrophy  of  the  left,  and  vice  versa.  The 
persistance  of  the  foramen  ovale,  the  perforation  of  the  septum 
between  the  ventricles,  the  ossification  of  the  sigmoid  valves  of 
the  aorta  or  of  the  mitral  valve,  excrescences  on  the  same  parts, 
and  accidental  productions  formed  in  the  heart,  are  of  much  rarer 
occurrence,  and  do  not,  generally  speaking,  impair  the  health, 
until  they  have  reached  such  a  degree  as  to  give  rise  to  hyper- 
trophy, or  dilatation  of  the  ventricles.  The  dilatation  and  hy- 
pertrophy of  the  auricles  are  rarer  still,  and  are,  perhaps,  always 
consecutive  affections  depending  on  previous  disease  of  the  valves 
or  ventricles. 

The  general  symptoms  of  all  these  affections  are  almost  the 
same  : — They  are,  an  habitually  short  and  difficult  respiration  ; 
palpitations  and  oppressions  constantly  produced  by  the  action 
of  ascending,  by  quick  walking,  by  emotions  of  mind, — or  with- 
out any  perceptible  cause ;  frightful  dreams,  and  sleep  frequently 


630  DISEASES    OF    THE    HEART. 

disturbed  by  sudden  starts ;  a  cachectic  paleness  and  a  tendency 
to  anasarca,  which  disease,  indeed,  comes  on  after  the  disease  has 
persisted  some  time.  To  these  symptoms  is  frequently  added 
the  Angina  Pectoris, — a  nervous  affection,  which  will  be  de- 
scribed hereafter.  When  the  disease  has  reached  a  high  degree, 
it  is  recognized  at  a  single  glance.  The  patient,  unable  to  bear 
the  horizontal  posture,  remains  night  and  day  sitting  rather  than 
lying  in  his  bed,  with  the  face  more  or  less  swollen,  sometimes 
very  pale,  but  more  commonly  of  a  deep  violet  blue  tint,  either 
over  the  whole  or  only  on  the  cheeks.  The  lips  are  swollen  and 
promient  like  a  negro's,  more  livid  than  the  rest  of  the  face,  or 
of  this  hue  when  it  is  quite  pale.  The  lower  extremities  are 
oedematus ;  and  the  scrotum  or  labia,  the  trunk  of  the  body, 
the  arms,  and  even  the  face,  are  successively  affected  in  the 
same  manner.  The  same  state  exists  in  the  serous  membranes, 
whence  arise  ascites,  hydrothorax,  and  hydropericardium,  which 
accompany  organic  affections  of  the  heart  more  frequently  than 
any  other  disease.  The  congestion  and  lentor  of  the  capillary 
circulation  are  further  shown  by  affections  of  the  internal  organs  ; 
for  instance — haemoptysis,*  pains  of  the  stomach,  vomiting,!  apo- 
plexy (which  frequently  terminates  such  affections,)  and  most  of 
all,  dyspnoea,  which  last  symptom  has  been  the  cause  of  con- 
founding such  diseases  (with  many  others)  under  the  name  of 
Asthma.  These  symptoms,  however,  as  they  show  themselves 
in  the  diseases  of  the  heart,  have  peculiar  characters  which  tend 
to  distinguish  them  from  such  as  occur  in  the  affections  most 
likely  to  be  confounded  with  them,  more  particularly  cases  of 
asthma,  which  depend,  for  the  most  part,  either  on  a  dry  catarrh 
or  a  morbid  condition  of  the  nervous  system. 

In  the  diseases  of  the  heart  the  general  circulation  is  not  al- 
ways so  much  affected  as  the  capillary.  Sometimes  the  pulse  is 
irregular,  but  sometimes  it  is  almost  natural ;  and  the  hand  ap- 
plied to  the  cardiac  region,  discovers  only  a  regular  and  moderate 

*  Haemoptysis  is  placed  by  most  practitioners  among  the  accidents  commonly 
occurring  in  organic  affections  of  the  heart.  This  is  a  great  mistake.  I  have 
paid  particular  attention  to  the  subject,  and  am  able  to  affirm  that  very  few  per- 
sons in  this  disorder  ever  spit  blood.  Pulmonary  apoplexy  is  of  more  frequent 
occurrence  in  this  disorder  than  any  other,  yet  even  in  cases  where  lire  lungs 
after  death  show  the  marks  of  this  lesion,  there  is  most  commonly  during  life 
no  expectoration  of  blood. — An&ral. 

t  I  hardly  think  the  vomitings  which  occur  sometimes  in  diseases  of  the 
heart,  can  be  owing  merely  to  a  congested  state  of  the  coats  of  the  Stomach. 
If  this  were  the  fact,  the  vomitings  would  be  much  more  common  than  they 
really  are  ;  because  in  any  serious  organic  afTection  of  the  heart,  the  coats  of 
the  stomach  and  the  intestines  become  the  seat  of  a  mechanical  hyperemia. 
The  vomitings  vyhich  sometimes  take  place  in  these  patients,  may  be  consid- 
ered purely  accidental.  They  indicate  a  complicated  state  of  irritation  or  in- 
flammation in  the  stomach;  and  very  often  proceed  from  indigestion  of  acrid 
substances  as  digitalis,  squills,  and  resinous  matter  given  as  hydrogogues.— 
JJndral. 


SYMPTOMS. 


631 


pulsation.  At  other  times  the  pulse  is  very  strong,  or  altogether 
imperceptible  ;  the  heart  yields  a  very  great  impulse,  or  none  at 
all,  its  contractions  are  evidently  irregular,  and  palpitation  is 
constantly  present  *     So  severe  a  state  of  disease  as  this,  is  not 

*  The  epitome  of  the  general  symptoms  given    by  our  author  is  excellent,  as 
far  as  it  goes  ;  but   it   must  he  admitted  that   the  paramount  importance   of  the 
auscultatory  diagnostics,  in   his   mind,  has   rendered   this  epitome   too   brief.     I 
would,  therefore,  recommend  to  the  reader's  attention  the  ampler  details  on  this 
subject  in  the  classical   works  of  Corvisart,   Testa,  Kreysig,  Berlin  and    Hope. 
In  the    latter  stages  of  organic  affections   of  the  heart,  the   diagnosis  is  always 
easy;  generally  even  without  the  aid  of  the  stethoscope,— almost  certainly  with 
it.     In"  the  very  earliest  stages,  however,  (the  only  period,  be  it  remembered, 
in  which  medical    treatment  can  be   of  much   use.)  the  practitioner  often  finds 
every  means  of  diagnosis,  whether  general  or  local,  insufficient  to  enable  him  to 
come  to  a  positive  conclusion.     It  is,  therefore,  of  the  greatest   consequence  to 
attend  to  the  symptoms  as  well  as  the  signs  of  these  diseases;  and  on  this  sub- 
ject much  valuable  information  will  be  obtained  from  the  works  already  referred 
to.     Corvisart  lays  much  stress  on  the  appearance  of  the  countenance,  consider- 
in"  it,  in  many  eases,  as  of  itself  sufficient  to  point  out  the  nature  of  the  disease. 
(p°385.)     This  author,  also,  as  well  as  Kreysig  and  Testa,  pays  much  attention 
to  the  state  of  the    mind  and  temper,  as  a  symptom  of  heart    affections  ;  irrita- 
bility, melancholy  and  despair,  being  stated   as  the   habitual  or  frequent  accom- 
paniments of  the  bodily  sufferings  of  these  unhappy  persons.  Testa,  in  particular, 
who,   as  well  as  Kreysig,  devotes   a  whole   chapter   to  this   subject,   considers 
suicide  as  by  no  means  a  rare  result  of  the  intolerable  misery  entailed  by  organic 
lesions  of  the  heart.     Every  one   must  have  witnessed  the  frequent  co-existence 
of  this  state  of    mind    with   cardiac   affections;    but  in  many  cases,  I   am   well 
assured  that  it  is  not  essentially  dependent  upon  these,  but  upon  a  state  of  bodily 
disorder   which    frequently    exists    without    any   accompanying    disease    of  the 
heart;— I   mean    that  complex   and   ill   understood   disorder,  commonly  termed 
hypochondriasis.     And,  indeed,  I  am  convinced  hy  experience  that  the  disease 
of  the  heart  itself  is  often  the  consequence  of  this  affection.     This  is  also    the 
opinion  of  Testa;  who  even   goes   so  far    as  to  consider  most    of  the  incurable 
cases  of  hysteria  and    hypochondriasis,  as   conjoined  with   incurable  diseases  of 
the  heart,     (vol.  ii.    p.  i>!t.)     Another  class  of  symptoms',  hardly  noticed   by  M. 
Laenncc,  but  highly  deserving  the  attention  of  practitioners,  are  those  referable 
to  disordered  or  diseased   stomach.     Corvisart,  Kreysig,  and   particularly  Testa, 
notice  this  state  of  the  stomach  at  some  length  ;  but  none  of  these  authors  con- 
sider it  in  its  highly  important  etiological  relations,  and  its  still    more  important 
bearings  on  the  treatment  of  the  cases  in  which  it  occurs.     Gastric  irritation — 
cerebral   irritation— cardiac  irritation,  constitute,  in   many  cases,   such  a  strong 
chain  of  disease,  every  part  of  which    influences   and   strengthens   every  other 
part,  that  no  plan  of  treatment  that  does  not  embrace  the  whole,  can  be  attended 
witli  success.— Haemorrhage  is  also  a  very  Common,  and  a  very  important  symp- 
tom in  diseases  of  the  heart.    It  is  highly  deserving  the  attention  of  practitioners, 
as  at  once  the  sign  of  the  disease,  a  sign  of  danger  to  other  organs,  and  a  natural 
indication   of  the   proper  treatment.     Burns,   and  after  him   Kreysig,  considers 
pains  in  other  parts  of  the  body  remote  fn  m  the  heart,  as  a   symptom  of  disease 
in    this  organ,  especially  of  chronic   inflammation   of  it.     Such   pains  no  doubt 
exist;  but  I  do  not   consider  them    as  at   all  peculiar  to   such   affections.— The 
position  assumed  by  patients  in  bed  is  an  important  symptom  of  diseased  heart, 
although  no  one  position  is  invariably  associated  either  with  the  diseases  in  the 
or<n\n  in  general,  or  with  any  of  the  forms  of  these.     I  have  frequently  verified 
the  truth  of  a  remark  of  Kreysig's,  (Sect.  III.  chap,  vii.)  that  the  assumption  of 
a  posture   previously  intolerable,  is   a  sign  of  extremely  bad   omen.     Syncope, 
epilepsy  and   apoplexy,  are  not   unusual   in  diseases  of  the   heart;  and  sudden 
death  is  too  frequently  their  closing    symptom.     The  character  of  the  syncope 
occurring  in  diseases  of  the  heart,  is  well  described  hy  Kreysig,  Sect.  III.  chap. 
iv. '     and   also  in  Dr.   Fany's    work    on    Angina;    and    its    frequency  is    suffi- 
ciently   illustrated   by    the  "fact  of    its   having   been  adopted    by  the    last-men- 


632  DISEASES    OF    THE    HEART. 

always  beyond  relief:  we  sometimes  see  the  judicious  combination 
of  bloodletting,  diuretics  and  tonics,  remove  the  impending  suf- 
focation, the  palpitations  and  dropsy,  and  restore  to  the  patient, 
frequently  for  a  long  period,  a  tolerable  degree  of  health :  and 
it  is  commonly  only  after  a  great  many  similar  attacks,  recurring 
after  considerable  intervals,  that  the  disease  at  length  proves  fatal.* 

tioned  author  as  the  name  of  what  he  considered  to  be  a  particular  disease,  but 
what  is  now  known  to  be  a  symptom  of  various  diseases  of  the  heart. — I  have 
myself  met  with  several  cases  of  convulsions  apparently  depending  on  disease 
of  the  heart,  and  numerous  cases  cf  the  same  kind  are  recorded  by.  authors. 
Among  others,  I  refer  the  reader  to  the  works  of  Bonetus,  Lancisi,  Morgagni, 
Greding,  Testa,  &c.  and  particularly  to  an  inaugural  dissertation  by  J.  J.  C. 
Moll,  "  De  arcto  inter  cordis,  morbos  convulsivosque  connexu."  Bonn,  1823. 
Several  cases  of  the  same  kind  are  noticed  by  Dr.  Farre  in  his  work  on  Malfor- 
mations of  the  Heart. —  Transl. 

*  Practitioners  cannot  pay  too  much  attention  to  facts  of  this  nature,  which 
are  far  from  being  uncommon.  Diseases  of  the  heart  may  bring  their  subjects 
to  the  brink  of  the  grave,  and  then  so  far  improve  as  to  allow  them  a  long  life. 
I  have  known  many  persons  attacked  with  dropsy  and  completely  cured.  A 
great  many  years  afterward  the  dropsy  appeared  again,  and  was  either  a  second 
time  cured,  or  continued  till  death.  Persons  suffering  from  aneurism  some- 
times have  eight  or  ten  returns  of  the  dropsy  before  they  sink  under  it  :  the 
oftener  they  are  repeated  the  more  difficult  is  a  recovery.  The  return  of  each 
attack  is  commonly  preceded  or  accompanied  by  an  exasperation  of  the  differ- 
ent accidents  of  the  disorder  of  the  heart.  The  dyspnoea  increases,  the  palpi- 
tations are  more  violent,  a  great  tumult  is  perceptible  in  the  precordial  regions, 
bellows-sounds  are  heard,  the  pulse  grows  irregular,  intermittent,  and  sometimes 
very  quick,  very  small,  &c.  All  these  accidents,  particularly  the  dropsy,  often 
disappear  as  if  by  enchantment,  upon  bloodletting.  But  it  must  not  be  for- 
gotten that  the  oftener  the  dropsy  returns,  the  less  efficacious  are  the  bleedings  ; 
and  finally  they  become  injurious  instead  of  beneficial.  Under  their  influence, 
the  serous  diathesis  which  at  first  was  conquered  by  them,  increases  :  the 
trouble  of  the  heart  augments,  and  asphyxia  threatens.  This  is  a  remarkable 
case  in  which,  considering  the  age  of  the  disease,  and  the  amount  of  strength 
possessed  by  the  patient,  the  same  symptoms  are  increased  and  diminished  by 
the  same  medical  treatment :  so  true  it  is  that  in  therapeutics  we  should  pay  more 
regard  to  the  dynamic  state  of  the  organs,  than  to  those  alterations  which 
merely  affect  the  senses.  There  are  cases  of  this'sort  where  nature,  as  Syden- 
ham observes,  suffices  without  any  active  treatment,  to  restore  order.  Thus  I 
have  lately  seen  at  La  Charite,  a  man  who  came  to  the  hospital  with  symptoms 
of  a  disease  of  the  heart  so  far  advanced  that  he  was  thought  at  the  point  of 
death.  His  face  was  livid  and  infiltrated,  his  limbs  swelled,  with  considerable 
ascites.  He  passed  his  nights  out  of  bed,  gasping,  his  limbs  hanging  down,  and 
his  body  propped  by  pillows  in  an  erect  position.  The  pulse  was  irregular  and 
hardly  perceptible,  yet  beat  160  in  a  minute:  the  heart  was  in  a  tumultuous 
motion,  difficult  to  describe.  I  despaired  of  his  life  so  utterly  that  I  did  not 
attempt  any  medical  treatment.  What  was  my  astonishment  a  few  days  after- 
ward to  find  the  serous  effusion  spontaneously  absorbed,  the  breathing  becom- 
ing free,  the  pulse  improving,  &c.  At  the  end  of  a  fortnight,  the  symptoms 
had  nearly  all  disappeared. — Anrlral. 

LITERATURE  OF  DISEASES  OF  THE  HEART  IN  GENERAL. 

1564.  Vega  (C.  A.)  De  cordis  et  thoracis  affectibus  (De  Arte  medendi.)    L.  BaU 

Fol. 
1580.  Bruno  (C.)  De  cordc  et  ejus  vitiis.     Basil.  4to. 
1584.  Ryff  (N.)  D.  de  affectibus  cordis.     Basil. 
1600.  Rudius  (Eustach.)  De  naturali  atque  morbosa  Cordis  conslitutione.  Vend. 

4to. 


CHANGES    OF    OTHER    ORGANS. 


633 


Sect.  II. — Of  the  Changes  produced  by  Diseases  of  the  Heart 
on  the  texture  of  other  organs. 

On  examining  the  bodies  of  persons  who  have  fallen  victims 
to  organic  affections  of  the  heart,  besides  the  structural  lesions 

1604.  Montagnana  (Barth.)  Consilia  de  oegritudinibus  cordis  (Opp.  select.)  Franc. 
1618.  Albertini  (Annibal)  De  affectionibus  cordis  Libri  tres.      Venet.  4to. 
1628.  Harvey  (W.,  M.D.)  De  motu  cordis  et  sanguinis  circulatione.     Franc.  4to. 

1656.  Tardy  (C.)  Traite  de  la  Monarchic  du  Coeur  en  1'Homme.     Par.  4to. 

1657.  Bulgetius  (Attil.)  De  affectionibus  cordis.     Patav.  4to. 

1666.  Smith  (John,  M.D.)  King  Solomon's  Portraiture  of  old  age.     Lond.  8vo. 

(Makes  Sol.  Discoverer  of  Circulation.) 
1669.  Lower  (Rich.,  M.D.)  Tractatus  de  Corde,  item  de  motu  et  calore  sanguinis. 

Lond.  8vo. 
1698.  Chirac  (Pet.)  de  Motu  Cordis.     Montpel.  12mo. 
1706.  Vieussens  (R.  de)  Nouvelles  dAcouvertes  sur  le  cceur.     Toulouse.  12mo. 

1715.  Vieussens  (R.de)  Traite  nouveau  de  la  structure  du  coeur, &c.  Toulouse.  4to. 

1716.  Kremer  (A.)  Diss,  de  morbis  qui  cor  et  respirationis  organa  infestant.  Vien. 
1723.  Martinez  (Mart.)  Observatio  rara  de  corde.     Madrid.  4to. 

1728.  Soumain  (le  Sieur.)   Relation  de  l'overture  du  corps  d'une  Femme  trouvee 

presque  sans  cceur  :  avec  l'histoire  de  la  maladie.     Par.  12  mo. 
1728.  Lancisi  (J.M.)  De  motu  cordis  et  aneurismatibus.     Rom.  Fol. 
172!).  Wood  (Wm.,  M.D.)  A  Mechanical  essay  upon  the  Heart.     Lond.  4to. 
1741.  Barbeyrac  (M.,  M.D)  Nouvelles  Diss,  sur  les  maladies  de  la  Poitrine,  du 

coeur,  <fcc.  JJmst.  12mo. 
1744.   Chirac  (Pet.)  De  motu  cordis  adversaria  analytica.     Par.  12mo. 
1749.  Senac  (Jo.)  Traite  de  la  structure  du  cceur,  et  de  ses  maladies.  2  vol. 

Par.  4to. 
1755-6 — 9.  Meckel  (J.  F.)  Obs.  sur  les  maladies  du  coeur  (Mem.  de  1'Acad.  de 

Berlin.) 
1761.  Matanus  (Ant.)  Deaneurysmaticis  Proecordiorum  morbis.     Liburn.  4to. 
176:?.   Mason  (II.)  Lectures  upon  the  Heart,  the  Pleura,  Lungs,  &c.  Reading.  8vo. 
1763.  Juncker  (C-F.)  Diss,  cordis  morbos  proprios  in  tabula  exhibens.    Hal.  4to. 
I /().").   Cruewell,  Diss,  de  cordis  et  vasorem  osteogenesi.     Hal.  4to. 

1772.  Sparventi,  Diss,  de  frequcntioribus  cordis  morbis.      Vienn.  4to. 

1773.  Neifeld  (J.  J.)  Ratio  medendi  morbos  circuli  sanguinei.     Bresl.  8vo. 
1778.  Petraglia  (Fr.)  De  cordis  affectionibus  syntagma.     Roma.  8vo. 

J 779.  Vandendale  (Lib.)  De  morbis  Cordis  (Diss.  Lovan.  I.)  4to. 

1785.  Michaelis  (C.  F.)  Aneurismatum  cordis  disquisito.  Hal.  4to.  (Doering,  I.) 

1785.  Walther  (J.  G.)  Sur  les  maladies  du  cceur  (Nouv.  Mem.  de  l'Acad.  Sc.  a 

Berlin.)     Berl.  4to. 
1790.  Reil  (J.  C.)  Diss.  Analecta  ad  historiam  cordis  pathologicam.     Hal.  4to. 
1792—5.  Ferriar  (J.,  M.D.)  On  Dilatation  of  the  Heart  (Med.  His.  and  Reflect. 

vol.  i.  ii.)     Lond.  8vo. 

1803.  Lesage  (L.A.)  Diss,  les  aneurismes  du  cceur.  4to.    » 

1804.  Portal  (Ant.,  M.D.)  Sur  les  maladies  du  coeur  (Anat.  Med.  t.  iii.)  Par.  8vo. 

1805.  Zuliani  Gibellini   (Franc,  31. D.)  de    quibusdam  cordis    affectionibus    aG 

prasertum  deejus  Prolapsu.     Brixim.  4to. 

1805.  Cabirau-Cabannes,  (J.F.M.)  Apergu  sur  quelques  affections  organiques  du 

coeur,  <fcc.     Par.  8vo. 

1806.  Herisse  (M.  le)  Propositions  sur  les  affections  organiques  du  coeur.  Par.  4to. 
1806.  Corvisart  (J.  N.,  M.D.)  Essai  sur  les  Mai.  du  cceur  et  des  gros  Vaiss. — 

Par.  4to. 
1806.  Petit  (M.  A.)  Essair  sur  la  Medicine  du  Coeur.  Lyon,  8vo. 

1808.  Contelle  (     )  D.  Essais  sur  quelques  causes  de  maladies  du  coeur.  Par.  8vo. 

1809.  Hamier  (F.)  Diss,  de  Morborum  cordis  diagnosi.      Goett. 

1809.  Warren  (J.  C,  M.D.)  Cases  of  Org.  Dis.  of  the  heart.     Boston,  (,1m.)  8vo. 
1809.  Burns  (A.)  Obs.  on  some  of  the   most  frequent  Diseases  of  the  Heart. 
Edin.  8vo. 

80 


634  DISEASES    OF    THE    HEART. 

and  the  serous  effusions  which  almost  always  accompany  these, 
we  find  all  the  marks  of  congestion  of  blood  in  the  internal  ca- 
pillaries. The  mucous  membranes,  especially  those  of  the  stom- 
ach and  intestines,  are  of  a  red  or  purplish  tint ;  and  the  liver, 
lungs  and  capillaries  situated  beneath  the  serous,  mucous  and 
cutaneous  tissues,  are  gorged  with  blood.  The  augmented  co- 
lor of  the  mucous  membranes  varies  much  in  degree  and  ex- 

1809.  Dundas  (D.)  An  account  of  peculiar  diseases  of  the  Heart  (Jfed.  Cliir. 

Trans,  vol.  i.)     Lond.  8vo. 

1810.  Pelletan  (P.  J.)  Mem.  sur  quelques  maladies  du  cceur,  (Clin.  Chir.)  Par. 
1810—11.  Testa  (A.,  M.D.)  Delle  Malattie  del  Cuore.     3  vol.  Bolog.  8vo. 
1812.  Wells  (W.  C,  M.D.)  On  Rheumatism  of  the  Heart  (Trans,  of  a  Soc.  for 

the  improvement,  &c.  vol.  iii.)     Lond.  8vo. 

1812.  Gates  (Jacob.)  On  Diseases  of  the  Heart.     Pkiladelph.  8vo. 

1813.  Le  Gallolis  and  Merat.  Diet,  des  Sc.  Med.  (Art.  Cmur.)  t.  v.  Par. 

1813.  Corvisart  (J.  N.)  A  Treatise  on  the  Diseases  of  the  Heart,  &c.  Trans,  by 

Hebb.  Lond.  8vo. 

1814.  Farre  (J.  R.,  M.D.)  Pathol.  Researches:  Essay  I.     On  Malconformations 

of  the  Human  Heart.     Lond.  8vo. 

1814.  Goigham  (J.)  On  Organic  Dis.  of  the  Heart,  (New  Eng.  Jour.  vol.  iii.) 

Boston. 
1814-17.  Kreysig  (D.  Fr.  Lud.)  Die  Krankheiten  des  Herzens,  <fcc.  Berlin.  8vo. 

1815.  Lukomski  (L.  P.)  De  statu  militum  morbis  cordis  gignendis  idonea.  Wien. 
1817.  Meckel  (J.  F.)  Tab.  Anat.  Pathol.  (Fasc.  I.  Cor.)  Lips.     Fol. 

1817.  James  (J.  H.)  Cases   of  disease  of  the  Heart,    &c.  (Med.    Chir.  Trans. 

vol.  viii.)     Lond.  8vo. 

1818.  Boeck  (A.  G.  L.)  De  statu  quodam  Cordis  abnormi.     Berol.  12mo. 

1819.  Theinhardt  (F.  J.)  Diss,  de  Paralysi  et  paresi  cordis.     Halle.  8vo. 

1819.  Mayer  (       )  Berichte   ueber  organische  fehler  des  herzens,  &c.  (Oestr. 

Med.  jahrb.  vol.  v.)      Wien.  8vo. 
1819-22.  Kreysig  (D.  F.  L.)  Le  Malattie  del  Cuore,  &c.  (Traduzione  di  Gui 
Ballarini.  vol.  vii.)     Pavia.  12mo. 

1820.  Wetzler  (J.  C.)     Ueber  krankheiten  des  herzens,  (Beitrage  zur  medicin, 

vol.  i.)  Mainz.  8vo. 

1821.  Reeder  (H.,  M.D.)  A  Pract.  Treat,  on  Diseases  of  the  Heart.     Lond.  8vo. 

1821.  Bartky  (C.  F.  E.)  Observ.  singul.  fungi  medullaris  in  corde.     Halle.  8vo. 

1822.  Beclard  <fc  Chomel,  Diet,  de  Wed.  (Art.  Cmur.)  t.  v.  Par. 
1824.  Bertin  (R.  S.J  Traite  des  Maladies  du  Cceur.     Par.  8vo. 

1824.  Cox  (Th.,  M.D.)  Obs.  on  Acute  Rheumatism  and  its  Metastasis  to  the 
Heart.     Lond. 

1824.  Abercrombie  (J.,  M.D.)  Contributions  to  the  Pathology  of  the  Heart,  (Tr. 

of  Med.  Chir.  Soc.  of  Ed.  vol.  i.)     Edin.  8vo. 

1825.  Parry  (C.  H.)  Collections  from  the  unpublished  writings  of  (vol.  ii.) — 

Lond.  8vo. 

1825.  Buger  (H.)  Diagnostik  der  hertzk  rankheiten.     Berl.  8vo. 

1826.  Andral  (G.)  Mafadies  du  cceur  et  de  ses-  dependances  (Clin.   Med.  torn. 

iii.)  Par.  8vo. 
1826.  Bernhardi  (       )  Obs.  circe  ingentem  cordis  tumorem.     Regiom.  8vo. 

1826.  Hawkins  (Fr.  M.D.)  Rheum,  and  some,  diseases  of  the  Heart  considered. 

Lond, 

1827.  Adams  (R.)  Cases  of  Dis.  of  the   Heart,  &c.  (Dub.   Hosp.  Rep.  vol.  iv.) 

Dublin. 

1828.  Brown  (J.,  M.D.)  Med.  Ess.  on  Fever,  Dis.  of  the  Heart,  &c.  Lond.  8vo. 

1829.  Andral  (G.)  Precis.  d'Anat.  Pathol,  vol.  ii.     Par.  8vo. 

1829,  Latham  (P.  M.,  M.D.)  Pathological  Essays  on  some  diseases  of  the  Heart. 

(Lond.  Med.  Gazette,  vol.  iii.)     Lond.  8vo. 

1830.  Bouillaud,  Diet,  de  Med.  et  Chir.  Pr.  (Art.  Cmur.)  t.  v.  Par. 

1830.  Elliotson,  (John,  M.D.)  on  the  recent  improvements  in  distinguishing  dis- 
eases of  the  Heart.     Lond.  Fol. 
1832.  Hope  (Jas.,  M.D.)Treatise  on  diseases  of  the  Heart,  &c.     Lond.  8vo. 


CHANGES    OF    OTHER    ORGANS. 


635 


tent.  Sometimes  it  is  observed  only  here  and  there,  under  the 
form  of  small  points  or  specks,  disseminated  over  the  surface  of 
the  membrane  :  at  other  times  it  occupies  the  whole  extent  of  the 
surface,  and  has  the  appearance  of  being  attended  with  some 
swelling  of  the  part.  These  two  appearances  are  sometimes  so 
considerable,  that  if  we  looked  to  them  merely,  without  examin- 
ing the  condition  of  the  heart,  and  without  reference  to  the  his- 
tory of  the  patient,  (who  had  perhaps  been  found  capable  of 
taking  into  his  stomach  wine  and  other  stimulant  matters  without 
experiencing  any  pain,  even  up  to  the  period  of  his  death,)  we 
might  be  tempted  to  believe  that  the  fatal  disease  had  been  a 
violent  inflammation  of  the  stomach  and  bowels.  In  fact,  the 
degree  of  redness  of  these  membranes  observed  after  diseases  of 
the  heart,  is  often  much  more  intense  and  extensive  than  is  found 
after  true  inflammation  of  these  parts,  as,  for  example,  in  dysen- 
tery ;  a  fact,  among  many  others,  sufficiently  proving  the  insuffi- 
ciency of  mere  redness  to  characterize  inflammation  of  the  mu- 
cous membrane  of  the  intestines,  any  more  than  the  purple  color 
of  the  face  in  asthmatic  patients  is  an  erysipelas.  In  persons 
who  have  died  of  disease  of  the  heart,  particularly  dilatation  of 
the  ventricles,  we  find  more  frequently  than  in  other  cases,  that 
intense  redness  of  the  inner  membrane  of  the  heart  and  large 
vessels,  which  I  shall  hereafter  notice  when  treating  of  the  dis- 
eases of  the  aorta. 

Lancisi  and  Senac,  after  Hildanus,  consider  gangrene  of  the 
limbs  as  a  consequence  of  disease  of  the  heart  and  large  vessels. 
The  late  Dr.  Giraud  was  of  the  same  opinion  ;  and,  since  his  time, 
many  practitioners  have  considered  the  gangrene  of  old  persons 
as  usually  caused  by  ossification  of  the  arteries.  M.  Corvisart 
justly  doubts  whether,  in  such  cases,  there  is  any  thing  else  but 
mere  coincidence  of  independent  diseases ;  and  I  think  that  the 
single  circumstance  of  the  rareness  of  the  spontaneous  gangrene 
of  the  limbs,  compared  with  the  frequency  of  disease  of  the 
heart  and  ossification  of  the  arteries,  is  sufficient  to  render  the 
thing  quite  improbable.*     This  is  equally  the  case  with  the  no- 

*  Testa  (torn.  iii.  p.  333)  and  Kreysig  (sect.  iii.  chap,  vii.)  are  of  the  same  opi- 
nion as  Laennec  :  yet  the  following  extract  from  Dr.  Carswell's  admirable  Trea- 
tise on  Mortification,  published  in  the  third  vol.  of  the  Cyclopaedia  of  Practical 
Medicine,  sufficiently  proves  that  the  ancient  opinion,  as  far,  at  least,  as  it  re- 
gards disease  of  the  Arteries  is  the  true  one.  "  In  every  case  of  gangrenea 
senilis  which  I  have  examined  after  death,"  says  Dr.  Carswell,  "I  have  found 
the  arteries  of  the  diseased  limb  obliterated  in  such  a  degree  as  to  interrupt  the 
circulation  of  the  blood.  The  obstructing  cause  consisted,  in  five  or  six  cases, 
of  a  fibrous  tissue  formed  either  in  the  walls  or  cavities  of  the  arteries,  whereby 
these  vessels  were  converted  into  nearly  solid  cords  of  ligamentous  consistence. 
This  state  we  have  traced  from  the  toes  more  than  half  way  up  the  leg :  it  was 
always  connected  with  ossification  of  the  larger  branches  and  trunks  of  the 
thigh  and  other  parts  of  the  body.  In  the  other  two  cases,  the  obstruction  de- 
pended on  extensive  ossification  of  the  principal  arteries   of  the   limb;    and  in 


(536  DISEASES    OF    THE    HEART. 

tion  of  Testa,  that  ophthalmia,  and  sometimes  the  loss  of  the 
eye,  may  be  ranged  among  the  consequences  of  diseases  of  the 
heart. 

None  of  the  symptoms  or  effects  mentioned,  suffice  to  charac- 
terize or  indicate  disease  of  the  heart,  since  they  are  common  to 
many  other  affections,  and  particularly  to  almost  every  chronic 
disease  of  the  lungs.  We  have  already  shown,  in  like  manner, 
that  neither  the  pulse  nor  the  action  of  the  heart,  as  ascertained 
by  the  touch,  supply  us  with  any  information  to  be  depended  on. 
To  mediate  auscultation,  therefore,  we  must  turn  as  affording  the 
only  means  of  recognizing  the  diseases  of  this  organ  ;  and  it  is 
proper  to  observe,  that  even  it  more  frequently  fails  in  this  case, 
than  in  any  of  the  other  diseases,  which  it  is  calculated  to  discover. 
I  have  already  shown,  that  the  study  of  the  heart's  actions  in 
health,  requires  much  more  time  and  application,  than  does  either 
the  voice,  respiration,  or  rhonchus.  Moreover,  when  we  are 
ignorant  of  the  previous  state  of  the  patient's  health,  as  is  almost 
always  the  case  in  hospital  practice,  we  may  sometimes  mistake 
mere  nervous  palpitations  for  hypertrophy  or  dilatation  of  the 
heart.  I  have  myself  never  fallen  into  this  error  without  discover- 
ing it  after  a  certain  time  ;  but  it  may  be  of  long  continuance 
if  we  only  examine  our  patients  after  long  intervals,  and  still  more, 
if  we  do  -not  do  so  during  a  state  of  repose.  Another  and  much 
more  insidious  cause  of  error,  is  supplied  by  those  diseases  of 
the  lungs  which  lessen  the  extent  of  respiration ;  such  as  pneu- 
monia, emphysema  in  a  high  degree,  and,  most  of  all,  chronic 
pleurisy.  In  cases  of  this  kind,  I  have  sometimes  found  the  heart 
enormously  dilated  or  thickened  on  examining  the  body  after 
death,  although  during  life,  the  contractions  of  this  organ  had 
been  perfectly  natural  in  respect  of  sound,  impulse  and  rythm.  It 
would  appear  as  if  the  diminished  action  of  the  lungs  obliges  the 
heart  to  modify  its  action.*  I  have  already  related  some  exam- 
ples of  this  fact,  (see  Cases  V.  VI.  VIII.  XXIV.)  These,  how- 
ever, are  by  no  means  common,  and  cannot  be  estimated,  even  in 
an  hospital,  at  more  than  one  in  twenty.  In  private  practice  the 
mistake  in  question  must  be  much  more  rare,  since  in  this  case  we 

several  others  it  was  produced  by  solid  fibrine  formed  around  spiculi  of  bone 
projecting  from  the  internal  surface  of  the  arteries." — It  is  equally  clear  from 
the  above  extract,  that  the  local  gangrene  cannot  be  regarded  as  any  sign  or 
proof  of  disease  of  the  heart. —  Transl. 

*  How  can  this  notion  be  reconciled  with  the  fact  that  in  persons  attacked 
with  severe  emphysema  of  the  lungs,  the  pulsations  of  the  heart  commonly  in- 
crease in  power  and  extent?  This  opinion  of  Laennec,  on  the  contrary,  agrees 
with  a  circumstance  constantly  observed  in  the  case  of  old  men.  After  death 
the  heart  is  often  found  in  a  state  of  hypertrophy,  with  ossification  of  the  valves 
which  border  its  orifices;  yet  there  may  have  been  no  palpitation,  nor  any 
symptom  of  disease  of  the  heart.  The  lungs  also  are  found  in  a  considerable 
degree  of  rarefaction. — AnAral. 


CAUSES. 


637 


almost  always  obtain  more  information  respecting  the  previous 
health  of  the  patients  even  than  we  require. 

Sect.  III. — Of  the  Causes  of  Diseases  of  the  Heart. 

The  causes  of  diseases  of  the  heart  are,  like  the  diseases  them- 
selves, various  in  their  nature.  Ossifications  are  the  result  of 
some  aberration  of  the  process  of  assimilation  which  is  not  easily 
understood.  Corvisart  inclined  to  the  opinion  that  the  excres- 
cences on  the  valves  originate  in  a  syphilitic  taint.  I  shall  after- 
wards state  another  opinion,  founded  on  the  mode  of  their  forma- 
tion. The  dilatation  and  thickening  of  the  ventricles,  diseases  of 
much  greater  frequency,  also  may  arise  from  various  causes ;  but 
these  are  in  general  more  easily  traced  to  their  sources  than  the 
former.  All  diseases  which  give  rise  to  severe  and  long-continued 
dyspnoea  produce,  almost  necessarily,  hypertrophy  or  dilatation 
of  the  heart,  through  the  constant  efforts  the  organ  is  called  on 
to  perform,  in  order  to  propel  the  blood  into  the  lungs  against 
the  resistance  opposed  to  it  by  the  cause  of  the  dyspnoea.  It  is  in 
this  manner  that  phthisis  pulmonalis,  empyema,  chronic  pneu- 
monia, and  emphysema  of  the  lungs,  act  in  producing  disease  of 
the  heart  ;*  and  that  those  kinds  of  exercise  which  require  great 
exertion,  and  thereby  impede  respiration,  come  to  be  the  most 
common  remote  causes  of  these  complaints.  On  the  other  hand, 
it  is  found  that  diseases  of  the  heart,  on  the  same  principle  of 
mutual  influence,  give  rise  to  several  diseases  of  the  lungs.  They 
are  thus  amongst  the  most  frequent  causes  of  oedema  of  the  lungs, 
haemoptysis,  and  pulmonary  apoplexy.  When,  however,  diseases 
of  the  heart  are  found  to  co-exist  with  chronic  pleurisy,  phthisis, 
emphysema,  and,  in  general,  with  chronic  disease  of  the  lungs,  it 
will  usually  be  found,  on  close  examination,  that  the  latter  are 
the  primary  diseases.  It  follows  from  these,  and  other  facts 
noticed  under  the  head  of  emphysema  and  pulmonary  catarrh, 
that  a  neglected  cold  is  frequently  the  original  cause  of  the  most 
severe  diseases  of  the  heart.  To  all  these  causes  must  be  added 
the  congenital  disproportion  between  the  size  of  the  heart  and 
the  diameter  of  the  aorta.  M.  Corvisart  has,  perhaps,  gone  too 
far  in  asserting  that  there  can  be  no  dilatation  of  the  heart  with- 
out the  previons  existence  of  a  disproportion  of  this  kind,  or  of  a 
contraction,  or  some  similar  obstruction  to  the  circulation,  at 
a  greater  or  less  distance  from  the  heart ;  it  is,  however,  true, 
that  it  is  very  common  to  find  an  aorta  of  small  diameter  in  cases 

*  It  would  seem  from  this  remark  that  diseases  of  the  heart  were  very  com- 
mon among  phthisical  subjects  :  but  this  is  not  the  fact.  Most  of  those  persons 
attacked  by  tubercles  in  the  lungs,  die  without  exhibiting  any  symptom  of 
orjranic  disease  of  the  heart. — Jlndral. 


638  DISEASES    OF    THE    HEART. 

of  hypertrophy  or  dilatation.  Still,  this  is  not  always  the  case, 
and  however  rational  such  a  cause  may  be,  we  can  readily  con- 
ceive many  others.  We  know  that  the  energetic  and  reiterated 
action  of  all  muscles  materially  increases  their  size,  as  in  the  case 
of  those  of  the  right  arm  of  the  fencer,  the  shoulder  of  the  porter, 
and  the  hands  of  most  artizans.  On  the  same  principle  we  must 
admit  that  even  nervous  palpitations,  or  such  as  originate  from 
moral  causes,  may,  by  frequent  recurrence,  produce  a  true  en- 
largement of  the  heart. 

There  is  yet  another  congenital  cause  of  disease  of  the  heart, 
which  appears  to  me  to  be  of  greater  frequency  than  the  small 
calibre  of  the  arota,  above  mentioned, — I  allude  to  a  dispropor- 
tionate thickness  of  one  or  both  sides  of  that  organ.  I  am  satisfied 
that  in  a  great  many  persons  the  parietes  of  one  or  both  sides  of 
the  heart  are  either  too  thick  or  too  thin  from  birth.  In  such 
cases  there  can  be  no  doubt  that  the  usual  exciting  causes,  moral 
and  physical,  will  be  more  apt  to  produce  formal  disease  of  the 
heart  than  in  individuals  in  whom  this  disproportion  does  not 
exist.* 


*  M.  Laennec's  account  of  the  causes  of  diseases  of  the  heart,  is  as  meagre  as 
his  detail  of  the  general  symptoms.  On  this  subject  also,  some  of  the  authors 
already  quoted,  and  particularly  Testa  and  Kreysig,  have  written  much  at  length, 
and  are  well  deserving  the  student's  attention.  I  shall  here  briefly  advert  to 
some  of  the  principal  causes  overlooked  or  not  sufficiently  noticed  by  our  au- 
thor. 

Moral  causes. — These  are  considered  by  Corvisart,  Testa  and  Kreysig,  as, 
either  immediately  or  remotely,  the  most  powerful  and  frequent  causes  of  dis- 
eases of  the  heart.  Many  well-known  instances  of  sudden  death  from  mental 
emotion — more  particularly  from  excessive  joy — through  rupture,  spasm,  or  pal- 
sy of  the  heart,  are  on  record.  Permanent  lesions  arise  from  similar  causes.  I 
had  lately  under  my  care  a  poor  woman  with  organic  disease  of  the  heart,  of 
many  months'  standing,  suddenly  produced  by  horror  at  seeing  her  infant  scald- 
ed to  death.  Both  Corvisart  (p.  384)  and  Testa  (t.  i.  p.  10)  assert  that  diseases 
of  the  heart  have  been  more  frequent  in  consequence  of  the  tremendous  agita- 
tion produced  by  the  French  Revolution  and  its  consequences.  This,  however, 
is  doubted  by  Bertin,  (p.  350,)  who  thinks  the  seeming  increase  of  such  cases 
is  rather  owing  to  their  being  hetter  understood  and  more  certainly  recognized. 
A  long  continuance  of  the  depressing  passions  may  act  in  various  ways  in  giv- 
ing rise  to  these  diseases, — e.  g.  in  directly  exciting  palpitation,  or  debilitating 
the  muscles  of  the  heart,  in  producing  disorder  and  disease  in  other  organs, 
which  may  act  indirectly  or  directly  on  the  heart,  &c.  However  they  act, 
their  influence  must  be  admitted  by  every  practitioner  of  experience.  See,  for 
example,  Case  IX.  in  my  work  entitled  "  Original  Cases,"  p.  138. 

The  strumous  habit. — This  is  considered  by  Testa  as  affording  a  strong  predis- 
position to  disease  of  the  heart;  my  own  experience  leads  me  to  the  same  con- 
clusion. In  this  case  I  have  thought  that  the  disease  is  developed  at  a  more 
early  age  than  under  other  circumstances.  Perhaps  in  this  case  an  original  dis- 
proportion of  parts  usually  exists. 

Disease  of  other  organs. — Besides  diseases  of  the  lungs,  noticed  by  our  author, 
diseases  of  other  organs  are  justly  considered  as  a  cause  of  affections  of  the 
heart.  Enlargement  of  the  liver,  so  commonly  observed  in  such  cases,  is  consider- 
ed by  Corvisart,  as  always  the  effect  of  the  disease  of  the  heart.  Testa  considers 
it  as  occasionally  a  cause.  Most  probably  it  may  be  merely  a  concomitant,  and 
the   consequence  of  those  chronic  disorders  of  the  stomach  and  upper  bowels, 


HYPERTROPHY    OF    THE    HEART. 


CHAPTER  II. 


639 


OF    HYPERTROPHY    OF    THE    HEATT. 

By  hypertrophy,  I  mean  simple  increase  of  the  muscular  sub- 
stance of  the  heart,  without  a   proportionate   dilatation   of  its 

which  are  too  frequent  in  all  classes  of  persons,  to  be  safely  admitted  as  either 
a  common  cause  or  effect  of  affections  of  the  heart.  This  and  other  obstructions 
of  the  abdominal  viscera  and  other  parts  remote  from  the  heart,  have  been  more- 
over supposed  to  act  directly  in  producing  disease  of  the  heart,  partly  by  com- 
pressing the  large  vessels  in  their  vicinity,  and  partly  by  blocking  up  the  capil- 
laries within  their  substance.  See  on  this  subject  Kreysig  (sect.  ii.  cap.  iii.)  and 
also  the  paper  of  Mr.  James  in  the  Med.  Chir.  Trans,  vol.  viii. 

Hereditary  causes. — There  can  be  no  doubt  that  diseases  of  the  heart  are  very 
frequently  hereditary,  although  the  character  in  which  the  predisposition  con- 
sists may  be  very  various  in  different  cases.  Some  striking  instances  of  this 
fact  are  recorded  by  Lancisi,  Albertini,  Morgagni,  Portal,  &c.  ;  and  Corvisart, 
(p.  370,)  and  Testa,  (t.  i.  p.  17,)  are  strong  supporters  of  the  same  opinion.  A 
striking  instance  of  this  kind  is  recorded  in  the  Med.  Comment,  vol.  ix.  p.  307; 
and  my  own  practice,  as  well  as  that  of  most  practitioners  of  experience,  would 
enable  me  to  add  many  to  the  catalogue. 

Cutaneous  disease. — We  are  too  little  in  the  habit,  in  this  country,  of  adverting 
to  the  ancient  doctrines  of  repulsion  as  a  cause  of  internal  disease.  There  can, 
however,  be  no  doubt  of  their  truth;  and  this,  I  believe,  is  as  conspicuous  in 
the  case  of  diseases  of  the  heart,  as  in  any  other.  The  foreign  writers  are  per- 
haps as  much  disposed  to  overrate  as  we  are  to  underrate  the  influence  of  this 
class  of  cases.  For  many  cases  of  cardiac  disease  supposed  to  originate  in  the 
repulsion  of  cutaneous  eruptions  I  refer  the  reader  to  the  works  of  Testa,  (t.  i. 
p.  119,)  and  Kreysig,  (sect.  ii.  cap.  iii.)  The  last  named  author  considers  the 
membranes  of  the  heart,  both  external  and  internal,  to  be  the  parts  chiefly  affec- 
ted in  such  cases,  a  circumstance  which  he  attributes  to  similarity  of  texture  ;  and 
he  states,  moreover,  that  in  certain  febrile  eruptive  diseases,  particularly  measles 
and  scarlatina,  he  has  found  these  membranes  simultaneously  inflamed  with 
the  skin. 

Syphilis. — The  opinion  of  Corvisart  alluded  to  in  the  text,  and  which  is  that 
of  many  other  writers,  particularly  foreign,  respecting  the  syphilitic  origin  of 
certain  affections  of  the  valves,  seems  extremely  doubtful,  if  not  improbable.  M. 
Bertin  states  that  an  experience  of  twenty  years,  at  the  venereal  hospital,  has 
led  him  to  consider  the  influence  of  this  cause  as  greatly  exaggerated,  (p.  232.) 

Gout.— It  hardly  admits  of  doubt,  that  gout  is  not  unfrequently  an  exciting 
cause  of  organic  lesions  of  the  heart;  and  it  is  probable  that  it  may  occasionally 
affect  this  organ  directly,  and  thereby  produce  death,  or  symptoms  resembling 
those  of  angina  pectoris.  Kreysig  is  a  strong  advocate  of  this  opinion,  (sect.  i. 
c.  3.)  which  is,  moreover,  corroborated  not  merely  by  the  peculiar  characters 
and  origin  of  gout,  but  by  the  testimony  of  most  writers,  and,  indeed,  by  the  ex- 
perience of  most  practitioners.  Dr.  Scudamore  in  his  work  on  Gout,  (4th  ed.) 
gives  a  remarkable  case  (p.  44.)  of  palpitation  of  the  heart  which  had  lasted 
three  years,  and  which  disappeared  the  very  day  on  which  an  attack  of  articu- 
lar gout  came  on  ;  and  the  same  author  quotes  a  similar  case  from  Dr.  Baillie, 
(p.  16.)  which  had  continued  six  months,  unrelieved  by  medicine,  but  was  in- 
stantly removed  on  the  supervention  of  gout.  Many  similar  cases  might  be 
mentioned.  I  consider  gout,  or  rather  that  modification  of  the  general  system 
usually  termed  the  gouty  habit,  as  by  much  the  most  frequent  cause  of  disease 
of  the  heart  in  advanced  life  ;  and  we  need  look  no  further  than  to  the  plethora, 
the  altered  condition  of  the  blood,  and  the  tendency  to  morbid  secretion,  which 
characterize  this  state,  to  see  a  ready  and  rational  explanation  of  the  fact. 

Rheumatism. — The  effect  of  rheumatism  in  occasioning  disease  of  the  heart  is 


640  HYPERTROPHY  OF  THE  HEART. 

cavities :  on  the  contrary,  these  are  most  commonly  considerably 
diminished  in  size.     This  affection  is  by  no  means  common,  and 

still  more  evident  than  that  of  gout,  and  is  universally  admitted  in  this  country. 
It  is  singular,  however,  that  this  cause  is  very  little  noticed  by  the  best  foreign 
writers  on  diseases  of  this  organ.  In  this  country  we  possess  several  excellent 
memoirs  on  the  subject,  particularly  those  of  Sir  David  Dundas,  Dr.  Wells,  Dr. 
Cox,  and  Dr.  Hawkins,  besides  numerous  cases  scattered  through  our  periodical 
journals.  Indeed  every  practitioner  of  experience  must  have  met  with  instan- 
ces of  the  kind.  I  have  myself  had  occasion  to  see  many  besides  those  recorded 
in  my  "  Original  Cases."  (See  Case  VI.  p.  112,  and  Case  XII.  p.  165,  in  that 
work.)  It  would  appear  from  the  result  of  the  dissections  that  have  been  made, 
that  the  most  common  effect  of  the  metastasis  of  rheumatism  to  the  heart  is  •peri- 
carditis, presenting  all  the  ordinary  symptoms  of  that  disease.  This  affection 
frequently  proves  fatal  in  the  acute  stage  :  sometimes  it  is  cured;  but  commonly, 
when  not  proving  fatal,  it  is  found  to  produce  enlargement  of  the  heart ;  and  in 
this  case  the  original  character  of  the  disease  is  discovered  after  death,  by  the 
presence  of  adhesions  between  the  heart  and  pericardium.  Sometimes,  how- 
ever, it  would  seem  that  the  muscular  substance  of  the  organ  is  alone  affected, 
and  the  consequence  of  the  attack  is  one  or  other  of  the  forms  of  hypertrophy  or 
dilatation.  For  instances  of  acute  pericarditis  succeeding  rheumatism,  the  reader 
is  referred  to  the  fifth  case  of  Dr.  Well's,  Dr.  Davis's  cases  of  Carditis,  some  of 
Dr.  Cox's  cases,  and  two  referred  to  by  Dr.  Hawkins,  at  p.  100  of  his  work. 

Although  rheumatism,  strictly  so  called,  is  no  doubt  the  frequent  source  of 
organic  diseases  of  the  heart,  I  have  been  led  by  my  own  observation  to  consid- 
er these  diseases  as  frequently  originating  in  common  idiopathic  inflammation 
of  some  part  of  this  organ.  At  least  I  have  met  with  many  cases  of  organic  dis- 
ease of  the  heart,  which  supervened  to  acute  attacks  of  what  I  considered  in- 
flammatory affections  of  the  heart  or  its  membranes,  unpreceded  and  unaccom- 
panied by  any  symptom  of  rheumatism.  See,  for  instance,  Cases  II.  p.  92,  and 
III.  p.  96,  in  "  Original  Cases."  I  observe  that  the  same  opinion  is  entertained 
by  Andral  in  his  recent  work — see  torn.  iii.  p.  459.  This  author  has  some  ex- 
cellent observations  on  this  subject. — He  considers  the  inflammations  which 
precede  hypertrophy,  to  be  commonly  situated  either  in  the  pericardium,  or  in 
the  inner  membrane  of  the  heart  or  aorta,  and  explains,  or  at  least  illustrates 
their  modus  operandi,  in  a  very  ingenious  manner.  (Op.  Cit.  460,  et  seq.) 
Burns  appears  to  consider  inflammation  of  the  heart  or  pericardium  as  the  con- 
sequence, rather  than  the  cause,  of  the  enlargement  of  the  organ.  (Op.  Cit.  p. 
58.)  It  is  more  than  probable,  that  in  some  of  his  cases,  at  least,  he  mistook  the 
effect  for  the  cause  ;  although  it  certainly  seems  reasonable  to  believe  that  hy- 
pertrophy of  the  heart  may  give  rise  to  inflammation  of  the  pericardium. 

Congenital  disproportion  of  parts  of  the  heart. — This  I  consider  with  our  au- 
thor as  the  most  frequent  cause  of  all,  at  least,  in  early  life,  and  as  the  source  of 
many  other  diseases,  even  before  it  can  be  said  to  amount  to  formal  disease  of 
the  heart.  See  a  valuable  chapter  on  this  subject  in  Testa  (torn  ii.  cap.  ii.)  to 
which  reference  ought  to  have  been  made  by  our  author. —  Transl. 

Since  the  publication  of  Laennec's  work,  researches  have  been  made  as  to 
the  influence  of  inflammation  of  the  pericardium  and  inner  membrane  of  the 
heart,  upon  the  development  of  diseases  of  this  organ.  In  the  first  edition  of 
my  Ctinique  Medicale,  I  had  already  called  attention  to  facts  of  this  kind  :  I  men- 
tioned pericarditis  as  one  of  the  affections  which  might  exert  a  real  influence  in 
the  production  of  hypertrophy  of  the  heart,  and  cited  cases  which  confirmed 
this  opinion.  In  the  same  work  I  also  affirmed  that  various  hypertrophies  of 
the  heart  might  proceed  from  an  inflammation  of  the  internal  membrane  of 
the  heart,  and  I  compared  this  hypertrophy  in  its  mechanism,  to  that  suffered 
by  the  fleshy  coat  of  the  stomach  subsequent  to  or  during  chronic  inflammation 
of  the  mucous  membrane  of  that  organ. 

The  recent  labors  of  M.  Bouillaud,  published  in  1826,  have  confirmed  my 
opinions  on  this  point,  as  well  as  that  which  1  announced  on  the  connexion  of- 
ten observed  between  rheumatism  and  the  subsequent  development  of  a  disease 
of  the  heart.  M.  Bouillaud's  researches  have  proved  a  coincidence  between 
rheumatism  and  certain  affections  of  the  heart,  much  more   frequent  than  had 


HYPERTROPHY    OF    THE    HEART. 


641 


appears  to  have  escaped  the  notice  of  M.  Corvisait,  as,  through 
his  whole  work,  he  seems  to  consider  increased  thickness  of  the 
walls,  as  being  uniformly  accompanied  by  a  proportionate  dilata- 
tion of  the  cavities  of  that  organ.*  This  thickening  of  the  heart 
is  always  attended  by  a  considerable  increase  of  its  consistence, 
except  when  conjoined  with  another  affection  of  this  organ,  to  be 
noticed  presently,  viz.  softening  of  the  heart.  Hypertrophy  may 
exist  in  one  or  both  ventricles,  with  or  without  a  similar  affection 
of  the  auricles.  Most  commonly  the  auricles  are  not  affected, 
but  occasionally  they  are  so,  while  the  ventricles  are  sound.  In 
some  few  cases  the  auricles  are  alone  affected  with  the  hyper- 
trophy. 

previously  been  suspected.  No  doubt  exists  at  the  present  day,  that  in  a  great 
many  acute  rheumatisms  of  the  joints,  the  internal  membrane  of  the  heart  has 
a  remarkable  tendency  to  inflammation.  I  shall  speak  hereafter  of  the  accidents 
which  this  must  occasion.  I  will  only  remark  here  that  it  will  be  generally 
impossible  without  the  help  of  auscultation,  to  discover  the  endocarditis  (or  in- 
flammation of  the  lining  membrane  of  the  heart)  which  is  thus  complicated  with 
rheumatism  or  follows  in  its  train.  We  thus  understand  readily  how  such  a 
disease  may  he  a  long  time  unpencived.  and  how  it  will  escape  observation  in 
must  cases,  unless  careful  auscultation  is  daily  practised  upon  the  hearts  of  rheu- 
matic patients.  I  have  no  doubt  of  the  great  influence  of  acute  articular  rheu- 
matism in  producing  organic  disease  of  the  heart.  Attentive  observation  has 
assured  me  on  the  one  hand,  that  a  great  number  of  individuals  with  lesions  of 
the  heart,  had  previously  had  acute  rheumatism,  and  that  from  this  time  they 
began  to  feel  troubles  at  the  heart,  as  palpitations,  dyspnoea,  &c. — On  the  other 
hand,  1  have  paid  daily  attention  to  the  state  of  the  heart  in  rheumatic  subjects, 
and  have  heard  in  a  manner,  the  disorder  arise  under  my  ear.  At  first,  either 
during  or  following  the  articular  pains,  there  is  a  bellows-sound,  faint  originally, 
but  increasing  every  day.  At  this  early  stage  of  the  malady  there  is  commonly 
no  pain  in  the  precordial  regions,  nor  palpitation,  nor  dyspnoea:  afterwards 
these  two  last  symptoms  appear,  and  are  usually  coincident  with  a  hypertrophy 
of  the  parietes  of  the  heart  arising  from  endocarditis ;  this  last  being  the  first 
lesion  which  accompanies  or  follows  the  rheumatism.  I  have  known  other 
cases  in  which  many  \  ears  after  an  acute  rheumatism  of  the  joints,  the  heart 
exhibited  no  other  symptom  than  a  bellows-sound.  In  such  cases  we  must  sup- 
pose a  contraction  of  one  of  the  orifices  of  the  heart,  which  is  not  accompanied 
(a  rare  circumstance)  by  any  thickening  of  the  coats  of  this  organ,  or  enlarge- 
ment of  its  cavities.  At  La  Charite  was  a  young  man  of  eighteen,  who  at  the 
age  of  12,  had  suffered  an  attack  of  very  strongly  marked  acute  rheumatism  of 
the  joints.  He  was  brought  to  the  hospital  for  a  slight  enteritis ;  otherwise  he 
had  never  suffered  the  least  accident  to  cause  the  suspicion  of  an  affection  of 
the  heart.  Yet  an  intense  bellows-sound  was  heard  in  the  precordial  regions, 
corresponding  with  the  moment  of  the  contraction  of  the  ventricles.  Care 
must  be.  taken  not  to  regard  endocarditis  as  the  cause  of  another  sort  of  bellows- 
sounds,  which  often  arise  in  rheumatic  patients  when  they  have  been  bled 
freely. — Jlndral. 

*  M.  Bertin,  in  bis  Traite  drs  Maladies  du  Cwur  et  des  gros  Vaisscaux,  pub- 
lished in  1924,  has  taken  pains  to  prove  the  separate  existence  of  hopertrophy 
and  dilatation  of  the  heart,  and  has  very  accurately  described  the  different  varie- 
ties of  these  affections :  and  it  appears  from  a  Report  made  to  the  Academy  of 
Sciences,  that  he  had  communicated  to  this  learned  body  a  memoir  containing 
these  distinctions,  so  early  as  1811.  I  never  conceived  myself  to  be  the  first 
who  noticed  the  distinction  in  question,  although  I  certainly  was  not  aware  that 
M.  Bertin  had  made  such  extensive  researches  on  the  subject,  else  I  would  have 
cited  them.  The  thing  had  been  noticed  in  particular  cases  by  others  before  the 
time  of  M.  Bertin,  for  instance  by  Morgagni,  Corvisan,  Burscrius,  and  more 
largely  by  Burns  and  Kreysig. — Author. 
PI 


642  HYPERTROPHY  OP  THE  HEART. 

When  affecting  the  left  ventricles,  I  have  seen  its  walls  more 
than  an  inch,  or  even  eighteen  lines  thick  at  the  base,  that 
is,  double  or  triple  their  size  in  the  sound  state.  Commonly, 
this  morbid  thickening  diminishes  insensibly  from  the  base  to  the 
apex  of  the  ventricle,  where  it  is  scarcely  perceptible  ;  sometimes, 
however,  the  apex  partakes  in  the  enlargement ;  as  I  have  seen  it 
from  two  to  four  lines  thick,  which  is  double  or  quadruple  the 
natural  size.  The  columnse  carnae  of  the  ventricles  and  the 
pillars  of  the  valves,  acquire  a  proportionate  enlargement.  The 
septum  between  the  two  ventricles  becomes  also  considerably 
thickened  in  the  disease  of  the  left  ventricle,  (which  fact  seems  to 
mark  it  as  belonging  to  this  rather  than  the  other  ventricle,)  but 
in  general  not  so  much  so  as  the  other  parts.  There  are,  how- 
ever, exceptions,  as  we  find,  (and  this  has  been  well  remarked  by 
M.  Bertin)  that  the  hypertrophy  is  sometimes  unequal  in  each 
part  of  the  ventricles,  or  occupies  only  a  single  point,  as  the  base, 
apex  or  middle,  the  septum  or  loose  part,  the  external  surface  or 
fleshy  columns.  The  muscular  substance  in  these  cases  is  of  a 
degree  of  consistence  sometimes  double  the  natural,  and  is  of 
a  redder  color.  The  cavity  of  the  ventricle  appears  frequently 
to  have  lost  in  capacity  what  its  walls  have  gained  in  thickness. 
Sometimes  I  have  found  this  so  small,  in  hearts  twice  the  size  of 
the  fist  of  the  individual,  as  scarcely  to  be  capable  of  containing 
an  almond  in  its  shell.  The  right  ventricle  in  such  cases,  being 
proportionably  smaller  as  the  hypertrophy  of  the  other  is  great, 
lies  flattened  along  the  septum,  and  does  not  extend  to  the  apex 
of  the  heart.  In  extreme  cases,  it  seems  as  if  it  were  merely  in- 
cluded within  the  walls  of  the  left  ventricle. 

In  hypertrophy  of  the  right  ventricle  the  appearances  are  some- 
what different.  The  thickening  is  here  more  uniform,  and  never 
so  great  as  in  the  other  ;  I  have  never  found  this  greater  than  four 
or  five  lines ;  M.  Bertin,  however,  (Op.  Cit.  Obs.  lxvii.)  found 
it  from  eleven  to  sixteen  lines,  in  a  case  where  the  foramen  ovale 
was  still  open ;  and  M.  Louis  has  described  a  similar  case  in  the 
Archives  de  Medecine  for  December,  1823.  It  is  always  a  little 
greater  in  the  vicinity  of  the  tricuspid  valves,  and  at  the  origin 
of  the  pulmonary  artery.  The  columnse  carnse  are  much  en- 
larged, considerably  more  so,  in  proportion,  than  those  of  the  left, 
in  disease  of  that  side ;  and  this  circumstance,  together  with  the 
increased  firmness  of  the  texture,  is  what  seems,  at  first  sight,  most 
remarkable  in  the  appearance  of  the  parts.* 

*  Bertin's  account  of  hypertrophy,  and  I  may  add,  of  all  the  other  affections  of 
the  heart  is  excellent.  He  divides  hypertrophy  into  three  species,  according  as 
the  natural  capacity  of  the  cavity  is  augmented,  diminished,  or  remains  unaltered, 
and  terms  them  respectively,  eccentric,  concentric,  ox  simple  hypertrophy.  I  give 
the  preference,  however,  with  Dr.  Hope,  to  the  old  nomenclature,  and  regard 
the  classification  of  this  gentleman  as  the  best.     It  will  be  seen  that  he  notices 


HYPERPROPHY    OF    THE    HEART.  643 

Signs  of  hypertrophy  of  the  left  ventricle. — It  is  to  this  variety 
of  the  disease,  especially,  that  the  symptoms  attributed  by  M. 
Corvisart  to  active  aneurism  of  the  heart,  must  be  referred  ;  and, 
indeed,  in  a  general  point  of  view,  and  speaking  with  a  degree  of 
accuracy  which  would  suffice  in  a  book  of  nosology,  like  that  of 
Sauvages  or  Cullen,  we  may  state  that,  besides  those  common  to 
all  diseases  of  the  heart,*  the  symptoms  of  the  hypertrophy  of  the 
left  ventricle  are  the  following  : — a  strong  full  pulse,  strong  and 
obvious  pulsation  of  the  heart,  perceived  as  well  by  the  patient, 
as  by  applying  the  hand,  absence  or  diminution  of  the  sound 
afforded  by  percussion  on  the  region  of  the  heart,  and  a  tint  of 
complexion  rather  red  than  purple.  None  of  these  symptoms, 
however,  are  constant ;  and  it  is  not  uncommon  to  find  the  dis- 
ease in  persons  who  have  none  of  them.  The  pulse,  in  particular, 
is  very  deceptive,  being  almost  as  frequently  weak  as  strong,  even 
in  the  worst  cases.f 

Inspection  of  the  chest  does  not  discover  the  pulsation  of  the 
heart,  except  in  thin  delicate  subjects,  and  indicates  nothing  more 
than  the  agitation  of  the  organ.  I  cannot,  in  this  respect,  agree 
with  M.  Bertin,  who  seems  to  attach  some  importance  to  the 
visible  degree  of  motion  impressed  upon  the  walls  of  the  chest  by 
the  action  of  the  heart.     Percussion  and  manual  examination  are 


one  variety  of  the  disease  not  named  by  Laenncc.     The  following  is  Dr.  Hope's 
arrangement : — 

1.  Simple  hypertrophy; — The  walls  thickened,  the  cavity  retaining  its  natural 
dimensions. 

2.  Hypertrophy  with  dilatation. — The  walls  cither  thickened  or  not  diminish 
ed,  the  cavity  enlarged. 

a.  The  walls  thickened,  the  cavity  dilated. 

b.  The  walls  of  natural  thickness,  the  cavity  dilated. 

3.  Hypertrophy  with  contraction. — The  walls  thickened,  the  cavity  diminish 
ed. —  Transl. 

*  Bertin  (Op.  Cit.  p.  359)  very  justly  insists  upon  a  striking  difference  in  the 
symptoms  of  simple  hypertrophy,  in  a  moderate  degree,  and  those  of  other  dis- 
eases of  the  heart.  In  this  case  he  truly  slates,  that  there  is  often  rather  an  in- 
creased energy  of  the  functions  of  health,  than  any  marked  derangement  of  these. 
Transl. 

t  This  view  of  the  state  of  the  pulse  in  hypertrophy  of  the  left  ventricle  is 
too  indefinite.  The  following  observations  by  Dr.  Hope  are  deserving  the  at- 
tention of  the  reader.  "  The  pulse  in  hypertrophy  of  the  left  ventricle  under- 
goes, from  valvular  and  other  lesions,  a  variety  of  modifications  which  disguise 
its  real  nature.  It  must,  therefore,  be  studied  in  cases  totally  exempt  from  com- 
plication. In  sucli  it  is  almost  invariably  regular  and  bears  strict  relation,  in 
strength  and  size,  to  the  thickness  and  capacity  of  the  left  ventricle.  Thus,  in 
simple  hypertrophy,  it  is  stronger,  fuller,  and  more  tense  than  natural ;  it  swells 
gradually  and  powerfully,  expands  largely,  dwells  long  under  the  finger,  and  is 
sometimes  accompanied  with  a  thrill  or  vibration.  These  characters  are  still 
more  marked  in  hypertrophy  with  dilatation  so  long  as  the  hypertrophy  is  pre- 
dominant; but  when  the  dilatation  has  proceeded  so  far  as  to  diminish  the  con- 
tractile power  of  the  muscular  fibres,  the  pulse,  though  still  full  and  sustained, 
is  still  soft  and  compressible.  In  hypertrophy  with  contraction  of  the  cavity, 
it  is  strong,  hard  and  tense,  but  small  and  cord-like,  expanding  little  under  the 
finger."     (Cyc.  of  Pract.  Med.  vol.  ii.  Art.  Hypertrophy.) — Transl. 


644  HYPERTROPHY  OF  THE  HEART. 

certainly  preferable  means  of  exploration,  but  even  these  become 
inapplicable  in  many  cases,  particularly  in  cases  of  considerable 
obesity  or  anasarca.  Mediate  auscultation  furnishes  signs  which 
are  much  more  constant  and  positive.  The  contraction  of  the 
left  ventricle,  examined  between  the  cartilages  of  the  fifth  and 
sixth  ribs,  gives  a  very  strong  impulse,  sufficient  to  elevate  the 
observer's  head,  and  is  accompanied  by  a  duller  sound  than  nat- 
ural ;  it  is  more  prolonged  in  proportion  as  the  thickening  is  more 
considerable.  The  contraction  of  the  auricle  is  very  short,  pro- 
ductive of  little  sound,  and  consequently  scarcely  perceptible  in 
extreme  cases.  The  sound  of  the  pulsation  of  the  heart  is  con- 
fined to  a  small  extent,  being  in  general,  scarcely  perceptible  un- 
der the  left  clavicle,  or  at  the  top  of  the  sternum  j*  sometimes  it 
is  confined  to  the  point  between  the  cartilages  of  the  fifth  and 
seventh  ribs.  The  impulse  of  the  heart  is  rarely  perceived  be- 
yond the  same  limits,  except  during  palpitation.! 

In  this  disease  the  patient  experiences,  more  constantly  than 
in  any  other,  the  sensation  of  the  action  of  the  heart ;  but  he  is 
less  subject  to  violent  attacks  of  palpitation,  except  from  acci- 
dental causes,  such  as  moral  affections  and  violent  bodily  exertion. J 
In  this  case,  during  the  palpitations,  irregularity  and  intermission 
of  the  pulse  are  uncommon  :  there  is  rather  increase  of  the  power 
of  the  ventricles  than  of  the  noise  produced  by  their  action. 
Sometimes,  however,  I  have  thought  that  certain  habitual  irreg- 
ularities of  the  pulse  and  heart,  in  subjects  who  in  other  re- 
spects, had  only  slight  marks  of  hypertrophy,  were  owing  to  the 
partial  thickenings  already  mentioned,  and  which  have  received 
particular  attention   from    M.  Bertin.<§>     Simple   hypertrophy    of 

*  The  pulsations  of  the  heart  beard  in  these,  and  in  points  still  more  remote, 
such  as  the  fore-part  of  the  right  side,  the  right  axillary  aspect,  or  the  back. — 
are  almost  always  owing  to  the  united  sounds  of  both  sides  of  the  heart;  some- 
times, however,  we  hear  the  sound  of  one  side  only,  even  in  the  most  distant 
points,  a  fact  which  becomes  quite  evident  when  the  sounds  of  the  two  sides 
are  very  dissimilar. — Author. 

t  When  the  hypertrophy  is  considerable,  the  parts  of  the  chest  struck  by  the 
heart  are  no  longer  the  same  .  thus,  instead  of  striking  between  the  fifth  and 
sixth  intercostal  spaces,  the  point  of  the  heart  hits  the  seventh  and  sometimes 
the  eighth  space.  The  base,  on  the  contrary,  is  observed  to  strike  nearer  the 
clavicle,  and  its  movements  may  be  perceived  as  far  as  between  the  third  and 
fourth  ribs.— Andral. 

X  The  most  common  modification  of  the  sounds  of  the  heart  in  hypertrophy, 
is  a  diminution  of  the  intensity  of  these  sounds,  which  grow  dull  as  the  coats 
of  the  heart  grow  thicker.  If  at.  the  same  time  its  cavities  are  to  a  certain 
degree  dilated,  the  metallic  clink  may  be  heard;  but  this  is  often  transient:  it 
takes  place,  for  instance,  during  the  palpitations,  and  ceases  with  them  ;  a  state 
of  repose  will  often  put  an  end  to  it.  As  to  the  bellows-sounds,  they  are,  to 
say  the  least,  very  uncommon,  in  cases  where  hvpertrophy  of  the  heart  is  un- 
accompanied by  contraction  of  the  orifices.— And  nil. 

§  When  the  heart  has  suffered  a  great  enlargement  either  from  hypertrophy 
of  its  parietes,  or  dilatation  of  the  cavities,  that  portion  of  the  walls  of  the  cfiesl 
in  connexion   with  it,   changes  its  dimension  ;  it   acquires  a  greater  convexity 


HYPERTROPHY  OF  THE  HEART.  C45 

the  left  ventricle  is,  of  all  the  affections  of  the  heart,  that  which 
most  frequently  gives  occasion  to  apoplexy.  In  M.  Bertin's 
work,  several  remarkable  instances  of  this  result  are  recorded 
(Obs.  lxxiv. — lxxx.)  ;  and  the  attention  of  practitioners  has  been 
more  particularly  called  to  it  by  MM.  Legallois  and  Richerand. 
Corvisart  considered  this  result  as  rarer  than  it  really  is.* 

Signs  of  hypertrophy  of  the  right  ventricle. — In  this  case,  ac- 
cording to  M.  Corvisart,  the  symptoms  are  the  same  as  when  the 
disease  is  on  the  other  side,  only  that  the  respiration  is  more 
oppressed,  and  the  color  of  the  face  is*deeper.f  He  adds  that, 
"  the  pulsations  of  the  heart,  which  are  most  evident  on  the  right 
side,  may  also  be  considered  as  signs  of  the  dilatation  of  the  right 
ventricle  ;  but  ....  this  sign  taken  by  itself,  is  of  little  value." 
(Op.  Cit.  p.   149.)     He  might  have  added,  that  we  cannot,  by 

than  the  corresponding  portion  on  the  right  side.  This  convexity  is  very  dis- 
tinct when  the  chest  is  examined  by  standing  at  the  foot  of  the  bed  while  the 
patient  lies  on  his  back.  I  have  several  times  noticed  the  correctness  of  this 
sign,  which  was  first  pointed  out  by  M.  Bouillaud.  It  is  not,  however,  alone 
sufficient  to  prove  the  existence  of  aneurism  of  the  heart,  as  it  occurs  also  in 
hydropericardium. — Qndral. 

*  For  some  ingenious  arguments  against  the  doctrine  of  apoplexy  being  a 
consequence  of  hypertrophy  of  the  left  ventricle,  I  refer  the  reader  to  a  very 
valuable  and  interesting  paper  by  Dr.  Kellie  in  vol.  i.  of  the  Edin.  Med.  Chir. 
Trans,  p.  123.  No  argument,  however,  can  rebut  the  evidence  of  such  facts  as 
have  been  adduced  in  support  of  the  doctrine  by  Bertin  and  many  others.  1 
have  myself  seen  a  good  many  instances  of  the  kind.  See  "  Original  Cases" 
III.  and  VII. — The  following  remarks  of  Dr.  Hope  are  in  accordance  with  my 
own  observation.  "  The  patient  complains  of  a  rushing  of  blood  to  the  head  on 
making  any  corporeal  effort  or  stooping  ;  of  intense  throbbing  and  lancinating 
head-aches,  aggravated  by  the  recumbent  position,  and  especially  by  the  act 
either  of  suddenly  lying  down  or  rising  up  ;  he  complains  also  of  vertigo,  tinnitus 
aurium,  scintillations  and  other  visual  illusions  ;  and  sometimes  of  a  lethargic 
somnolency  which  so  completely  subdues  the  faculties  both  of  the  mind  and  the 
body,  as  utterly  to  incapacitate  him  for  every  species  of  exertion.  These  symp- 
toms, if  not  relieved,  terminate  in  palsy  or  apoplexy.  From  this  catastrophe 
the  patient  is  often  preserved  by  epistaxis  to  which,  happily,  he  is  peculiarly  lia- 
ble."    (Cyc.  of  Pract.  Med.  Ibid.) — Transl. 

t  The  following  remarks  of  Dr.  Hope  respecting  the  state  of  the  complexion 
in  hypertrophy  are  ingenious,  and  on  the  whole  accord  with  my  own  observa- 
tion. "  The  effect  of  hypertrophy  is  to  brighten  the  color  so  long  as  the  capil- 
lary circulation  continues  unembarrassed,  but  afterwards  to  diminish  and  change 
it.  Every  individual,  however,  does  not  acquire  a  florid  color.  Whether  he 
acquire  it  or  not,  depends,  in  truth,  upon  the  original  complexion,  the  series  of 
changes  being  different  in  those  who  are  naturally  florid  and  those  who  are  pale. 
In  the  former,  the  color  becomes  remarkably  vivid,  and  being  generally  accom- 
panied with  plethoric  turgescence,  it  gives  the  aspect  of  health  and  good  con- 
dition. But  when  the  capillary  circulation  begins  to  labor,  the  red  changes  in- 
to a  purplish  path  on  the  cheeks,  the  nose  and  lips  become  more  or  less  purple, 
violet,  or  livid,  and  the  intermediate  skin  becomes  sallow  and  cachectic.  In 
great  hypertrophy  with  dilatation,  the  purple  and  violet  colors  are  sometimes  of 

the  deepest  dye In  those    who  are  naturally    devoid  of  color,  hypertrophy 

either  does  not  excite  it  at  all,  or  merely  increases,  in  a  slight  degree,  the  general 
vascularity  of  the  face.  This  vanishes  entirely  when  the  capillaries  become 
obstructed,  and  is  superseded  by  universal  cadaverous  paleness,  extending  some- 
times even  to  the  lips.  They,  however,  are  generally  somewhat  livid."'  (Cyc. 
of  Pract.  Med.  Ibid.)— Transl. 


646  HYPERTROPHY    OP    THE    HEART. 

means  of  the  hand,  perceive  the  action  of  the  heart  on  the  right 
side,  except  in  cases  where  this  organ  is  displaced  by  an  effusion 
or  tumor  in  the  left  side  of  the  chest.  Lancisi  has  mentioned 
the  swelling  of  the  external  jugular  veins,  with  a  pulsation  anal- 
ogous to  that  of  an  artery,  as  a  sign  of  the  aneurism  of  the  right 
ventricle.  M.  Corvisart  has  rejected  this  symptom,  because  he 
says,  "  it  has  been  found  in  cases  where  the  left  side  of  the  heart 
was  dilated,  and  because  the  pulsation  may  be  confounded  with 
that  of  the  carotids."  In  this  opinion  I  differ  from  M.  Corvisart. 
I  have  uniformly  found  this  symptom  in  every  case  of  this  kind, 
of  any  degree  of  severity  ;  and  I  have  never  met  with  it  in  hy- 
pertrophy of  the  left  ventricle,  unless  there  existed,  at  the  same 
time,  a  similar  affection  of  the  right.  One  must  be  very  inat- 
tentive, or  have  never  witnessed  these  pulsations  of  the  jugulars, 
to  confound  them  with  movements  occasioned  by  the  pulsation  of 
the  carotids.  It  is  likewise  worthy  of  notice,  that  this  pulsation 
of  the  jugulars  is  commonly  confined  to  their  inferior  portion, 
where  the  vein  and  artery  lie  much  further  asunder  than  in  the 
middle  of  the  throat.  Sometimes,  however,  this  reflux  of  the 
blood  extends  wider,  and  even  beyond  the  jugulars.  Hunauld 
has  seen  it  very  perceptible  in  the  superficial  veins  of  the  arm.* 
I  myself  saw  a  similar  case  last  year ;  and  in  a  large  vein  of  the 
size  of  a  goose-quill,  which  joined  the  jugular,  I  also  observed 
very  distinctly  a  pulsation  isochronous  with  the  pulse.  I  would, 
therefore,  be  disposed  to  regard  this  symptom  as  one  which  ought 
to  lead  us  to  suspect  the  existence  of  the  thickening  of  the  right 
ventriclcf 

The  contractions  of  the  heart,  as  explored  by  the  stethoscope, 
give  the  same  results  precisely,  whether  the  hypertrophy  be  on 
the  right  or  left  side ;  only,  in  the  former  case,  the  shock  of  the 
heart's  action  is  greater  at  the  bottom  of  the  sternum  than  be- 
tween the  cartilages  of  the  fifth  and  seventh  ribs,  which  is  the 
reverse  of  what  happens  when  the  disease  is  in  the  left  side  of 

*  Mem.  de  l'Acad.  des  Sc. 

t  Bertin  (p.  364.)  says  this  state  of  the  jugulars  is  not  observed  except  in  the 
case  where  the  ventricle  is  dilated  as  well  as  hypertrophied,  and  when  the  au- 
riculo-ventricular  orifice  is  unusually  large.  Testa  (t.  iii.  p.  321)  disbelieves  the 
frequency  of  this  sign  ;  but  Dr.  Hope  regards  it  as  one  of  the  best  general  signs 
of  hypertrophy  of  the  right  ventricle,  more  especially  when  accompanied  with 
dilatation.  The  following  remarks  by  Dr.  Hope,  on  the  differences  between 
this  condition  of  the  jugulars  and  pulsation  of  the  carotids  are  worthy  of  notice. 
"  The  jugular  pulsation  is  double — a  weaker  pulsation  occasioned  by  the  au- 
ricular systole,  preceding  that  occasioned  by  the  ventricular  systole.  . . .  The  ju- 
gular pulsation  is  confined  to  the  lower  part  of  the  neck,  and  is  far  in  the  hu- 
meral side  of  the  carotid.  The  pulsations  of  the  artery,  on  the  contrary,  ex- 
tend as  high  as  the  angle  of  the  jaw,  and  in  the  direction  of  the  anterior  margin 
of  the  mastoid  muscle.  The  jugular  turgescence,  again,  disappears,  in  some  de- 
gree, during  inspiration,  and  re-appears  in  expiration,  which  movements,  there- 
fore, must  not  be  confounded  with  the  pulsations  answering  to  the  systole  of  the 
ventricle."  (Ibid.) — Transl. 


HYPERTROPHY    OF    THE    HEART. 


647 


the  organ.  In  most  men,  in  health,  the  heart  is  heard  equally 
in  both  these  places.  In  those  who  have  no  mark  of  diseased 
heart,  however,  we  sometimes  hear  the  sounds  better  under  the 
sternum  than  the  cartilages ;  and  I  am  disposed  to  consider  this 
as  constantly  indicating  a  marked  predisposition  to  hypertrophy 
or  dilatation  of  the  right  ventricle. 

I  consider  this  sign  drawn  from  the  place  where  the  heart  is 
heard  and  felt  beating  with  the  most  force,  as  altogether  certain. 
I  have  proved  its  truth  so  often  by  dissection,  that  I  look  upon  it 
as  infallible  when  well-marked.  A  very  interesting  case  will  be 
detailed  under  the  head  of  ossification  of  the  valves,  which,  al- 
though devoid  of  the  absolute  certainty  supplied  by  dissection, 
will,  I  conceive,  afford  incontestable  proofs  of  this  fact.  Never- 
theless, there  is  still  one  exception  to  this  rule.  When  the  left 
ventricle  has  acquired  an  enormous  size  from  hypertrophy  and 
dilatation,  and  the  right  still  remains  small,  the  former  becomes 
quite  anterior  and  the  last  posterior :  in  this  case,  the  pulsations 
of  the  left  ventricle  are  perceived  much  better  under  the  sternum, 
than  in  the  left  precordial  region,  while  those  of  the  right  are  not 
perceived  at  all.  We  may,  however,  ascertain  the  truth  in  this 
case,  by  observing  that  there  is  no  reflux  of  blood  in  the  veins. 
Simple  hypertrophy  without  dilatation  is  much  more  rare  in  the 
right  than  in  the  left  ventricle.* 

In  Hypertrophy  of  both  ventricles  at  the  same  time,  the  en- 
largement extends  on  both  sides  to  the  apex  of  the  heart,  and  the 
anatomical  characters  already  mentioned  co-exist.  The  signs  of 
this  affection  consist  in  the  re-union  of  those  that  belong  to  hy- 
pertrophy of  each  side  ;  only  those  of  the  right  side  are  almost 
always  more  marked.f 

*  Hypertrophy  of  the  right  ventricle  appears  to  exert  the  same  influence  over 
the  lungs  as  the  left  does  over  the  brain,  predisposing  to  pulmonary  apoplexy 
and  haemoptysis.  Bertin  and  Bouillaud  notice  several  cases  of  this  sort,  and 
wish  to  separate  these  active  arterial  haemorrhages  from  the  venous  haemor- 
rhages, pulmonary  or  others,  so  common  in  the  latter  stages  of  all  diseases  of 
the  heart.  But  I  am  of  opinion  that  there  is  more  theory  than  actual  observa- 
tion in  these  distinctions. — (M.  L.) 

t  Hypertrophy  of  the  heart,  when  not  extensive,  and  not  accompanied  with 
great  dilatation  of  the  cavities  nor  contraction  of  the  orifices,  is  not  indicated 
by  very  grave  symptoms.  In  repose  at  least,  the  dyspnoea  is  slight,  the  venous 
circulation  very  little  disturbed,  and  consequently  there  are  rarely  collections  of 
serosity  in  the  cellular  tissue  or  the  peritoneum.  Yet  these  accidents  may 
occur  when  the  patient  is  much  fatigued  or  has  suffered  violent  emotion:  and 
on  the  other  hand,  the  hypertrophy  may  be  completely  latent,  if  the  state  of 
quiet  be  rigorously  maintained. — Andral. 


648  DILATATION    OF    THE    HEAIlT. 


CHAPTER  III. 

OF    DILATATION  OF    THE    VENTRICLES. 

Anatomical  characters. — This  disease  of  the  heart,  which  has 
been  named  passive  aneurism  by  M.  Corvisart,  consists  in  dila 
tation  of  the  cavities  of  the  ventricles,  with  increased  thickness 
of  their  walls.  With  these  conditions  there  are  commonly  con 
joined  a  marked  degree  of  softening  of  the  muscular  substance, 
and  a  color  more  purple  or  paler  than  natural.  Sometimes  the 
softness  is  so  considerable,  especially  in  the  left  ventricle,  that  the 
muscular  substance  can  be  destroyed  by  mere  pressure  between 
the  fingers  ;  and  the  walls  of  the  same  ventricle  may  be  so  much 
diminished  in  thickness,  as  to  be  only  two  lines  in  the  thickest 
point,  and  scarcely  half  a  line  at  the  apex,  while  the  right  ven- 
tricle is  sometimes  so  completely  extenuated,  as  to  appear  merely 
composed  of  a  little  fat  and  its  investing  membrane.  The  co- 
lumnae  carnae,  particularly  of  the  left  ventricle,  are  more  apart 
than  in  the  natural  condition  of  the  parts.  The  septum  between 
the  ventricles  loses  less  of  its  thickness  and  of  its  consistence 
than  the  rest  of  the  parietes. 

Dilatation  may  be  confined  to  one  ventricle,  although  it  more 
commonly  affects  both  at  the  same  time ;  and  this  is  the  more 
remarkable  as  being  the  reverse  of  what  takes  place  in  hypertro- 
phy of  the  same  parts.  When  one  only  is  affected,  the  apex  of 
it  extends  below  the  other,  but  not  in  so  remarkable  a  degree  as 
in  the  case  of  hypertrophy.  The  augmentation  of  the  cavity 
seems  to  be  more  in  its  breadth  than  length.  This  is  particularly 
observable  when  both  the  ventricles  are  dilated  at  the  same  time ; 
as,  in  this  case,  the  heart  assumes  a  rounded  shape,  being  nearly 
as  wide  at  the  apex  as  at  the  base. 

Burns  is  of  opinion  that  dilatation  may  be  carried  so  far  as  to 
occasion  rupture  of  the  cavities.  This  seems  possible  ;  and  the 
more  so  from  the  almost  constant  co-existence  of  softening  of  the 
parts  ;  but  I  know  of  no  example  of  the  kind.  We  must  not 
confound  with  dilatation,  the  distention  of  the  cavities,  depend- 
ing on  their  infarction  with  blood,  during  the  last  moments  of  life. 
But  it  is  sufficient  to  know  the  circumstance,  to  prevent  such  a 
mistake.  Many  hearts  which  seem  voluminous  upon  cutting  into 
the  pericardium,  lose  this  appearance  when  the  cavities  are  laid 
open. 

M.  Bertin  is  of  opinion  that  dilatation  of  the  heart  is  always 
occasioned  by  some  obstacle  to  the  course  of  the  blood,  such  as 
ossification  of  the  valves,  congenital  narrowness  of  the  aorta  and 


SIGNS    AND    SYMPTOMS. 


649 


pulmonary  artery,  the  influence  of"  certain  employments  which 
induce  laborious  efforts,  and  diseases  of  the  lungs.  The  effects 
of  these  causes  must  be  admitted ;  but  I  am  of  opinion  that  the 
most  powerful  cause  of  all  is  the  congenital  disproportion  of  the 
parts  of  the  heart.  Dilatation  is  most  common  in  women,  who, 
generally  speaking,  have  the  walls  of  the  ventricles  thinner  than 
those  of  men.* 

Signs  of  the  dilatation  of  the  left  ventricle. — The  symptoms 
of  this  affection,  according  to  Corvisart,  are — "a  soft  and  weak 
pulse,  and  feeble  and  indistinct  palpitations  : — the  hand  applied 
to  the  region  of  the  heart  feels  as  if  a  soft  body  elevated  the  ribs, 
and  did  not  strike  these  with  a  sharp  and  distinct  stroke.  It  ap- 
pears as  if  we  could  diminish  the  palpitation  by  strong  pressure." 
(Op.  Cit.  p.  147.)  I  formerly  stated  my  opinion  respecting  the 
pulse  as  a  sign  of  disease  of  the  heart ;  and  in  respect  to  the  in- 
formation to  be  obtained  by  the  application  of  the  hand,  I  must 

*  The  following  remarks  by  Dr.  Hope  on  the  causes  of  dilatation,  and  par- 
ticularly with  reference  to  hypertrophy,  are  deserving  of  notice.  "The  excit- 
ing causes  of  dilatation  are,  1st,  deficient  power  of  the  heart,  whether  con- 
genital or  acquired,  in  proportion  to  the  system;  2nd,  in  general  terms,  all  ob- 
structions to  the  circulation,  whether  situated  in  the  orifices  of  the  heart  or  in  the 
aortic  or  pulmonary  system.  The  latter  class  of  causes  are,  in  fact,  essen- 
tially the  same  as  the  exciting  causes  of  hypertrophy  ;  for  it  depends  on  the  pro- 
portion which  the  resistance  of  the  muscle  bears  to  the  distending  force,  whether 
the  one  affection  or  the  other  is  produced.  When,  therefore,  dilatation  occurs 
in  one  of  the  cavities  with  naturally  thick  walls,  in  which  we  should  more 
properly  expect  hypertrophy,  it  must  be  ascribed  either  to  a  congenital  dispro- 
portion of  the  heart,  in  consequence  of  which  the  cavity  in  question  is  thinner 
and  therefore  more  disposed  to  dilatation  than  natural ;  or  it  must  be  attributed 
to  the  obstruction,  from  its  nature  or  situation,  bearing  more  in  proportion  on 
that  particular  cavity  than  on  any  other.  It  is  from  having  overlooked  these 
considerations  respecting  the  relations  of  the  resisting  and  distending  forces  to 
each  other,  that  sonic  have  excluded  dilatation  from  the  catalogue  of  mechanical 
diseases,  and  supposed  that  it  takes  its  rise  in  any  cavity  of  the  heart,  either  by 
chance  or  by  some  \  ital  predilection — some  vague,  unintelligible  predisposition." 
(Cyc.  of  Pract.  Med.  Art.  Dilatation,  vol.  i.) 

M.  Berlin  divides  dilatation,  as  well  as  hypertrophy,  into  three  species — viz. 
according  as  the  walls  of  the  dilated  cavity  arc  thicker  or  thinner  than  natural, 
or  still  retain  their  natural  thickness.  Tin-  first  of  these  is  that  noticed  by 
him  under  the  former  head,  and  termed  rm  ntric  hypertrophy.  He  says  a  fourth 
variety  may  be  added,  namely,  where  the  walls  of  the  affected  cavity  are 
thickened  in  some  parts,  extenuated  in  some,  and  of  the  natural  thickness  in 
others.  This  author  admits  that  the  muscular  substance  may  be  softened  and 
discolored  in  dilatation,  but  he  considers  these  states  as  mere  complications,  and 
not  essential  to  constitute  the  disease.  Of  the  two  classes  of  enlargement  of 
the  heart,  he  wishes  the  first  to  be  exclusively  distinguished  by  an  increased 
thickness  of  the  walls,  and  the  second  by  an  increased  capacity  of  the  cavities. 
One  of  thespecies  of  dilatation,  that,  namely,  in  which  the  wallsof  the  enlarged 
cavity  retain  their  natural  thickness,  is  supposed  by  M.  Berlin,  not  to  have  been 
formerly  noticed  before  the  publication  of  his  work.  In  this  he  is  mistaken, 
however,  as  it  was  noticed  both  by  Bums  and  Kreysig.  M.  Bertin  terms  it  sim- 
ple dilatation,  and  states  it  to  be  of  almost  as  frequent  occurrence  as  the  eccen- 
tric hypertrophy,  or  hypertrophy  with  dilatation.  It  is  well  observed  by  this 
author,  that  the  orifices  of  the  heart  frequently  partake  in  the  dilatation  of  the 
cavities,  insomuch  that  the  valves  become  insufficient  to  close  them. —  Transl. 
82 


650  DILATATION    OF    THE    HEART. 

say  that  in  most  cases  I  have  not  found  the  action  of  the  heart  at 
all  perceptible  in  this  way.  In  like  manner  I  have  frequently 
found  the  sound  on  percussion  pretty  good  in  cases  of  consider- 
able dilatation.  The  only  certain  sign  of  the  existence  of  this 
disease  is  that  given  by  the  stethoscope,  viz.  the  clear  and  sono- 
rous contractions  of  the  heart  between  the  cartilages  of  the  fifth 
and  seventh  ribs.  The  degree  of  distinctness  of  the  sound,  and 
its  extent  over  the  chest,  are  the  measure  of  the  dilatation  :  thus, 
when  the  sound  of  the  contraction  of  the  ventricles  is  as  clear 
as  that  of  the  contraction  of  the  auricle,  and  if  it  is,  at  the  same 
time,  perceptible  on  the  right  side  of  the  back,  the  dilatation  is 
extreme.* 

Signs  of  the  dilatation  of  the  right  ventricle. — According  to 
M.  Corvisart,  the  state  of  the  pulse,  and  the  pulsation  of  the 
heart,  are  very  nearly  the  same  as  in  dilatation  of  the  left  ven- 
tricle, only  that  the  action  of  the  heart  is  heard  somewhat  better 
towards  the  bottom  of  the  sternum  and  epigastriurri,  than  in  the 
region  of  the  heart.  He  attaches,  however,  but  little  importance 
to  this  sign,  as  well  as  to  that  first  noticed  by  Lancisi, — the 
swollen  state  of  the  jugulars.  More  certain  symptoms  he  con- 
siders to  be — a  greater  degree  of  oppression,  more  marked  serous 
diathesis,  more  frequent  haemoptysis,  and  a  more  livid  state  of 
the  countenance, — than  in  the  affection  of  the  left  ventricle. — 
This  detail  of  symptoms  is  generally  accurate  ;  but  I  must  differ 
from  my  celebrated  master  respecting  the  importance  of  two  of 
them,  I  mean  the  state  of  the  jugulars,  and  the  extent  of  space 
in  the  cardiac  region,  whence  percussion  elicits  a  dull  sound.  An 
habitually  swelled  state  of  these  veins  without  sensible  pulsation, 
has  appeared  to  me  the  most  constant  and  characteristic  of  the 
equivocal  signs  of  this  affection.  This  condition  of  the  jugulars 
is  not  removed  by  compression  of  the  veins  at  the  upper  part  of 
the  neck.  In  respect  of  the  signs  furnished  by  percussion,  1  have 
frequently  found  the  right  cavities  very  much  dilated  in  subjects 
whose  chests  sounded  very  well  in  the  cardiac  region  and  under 
the  sternum ;  and,  generally  speaking,  it  has  appeared  to  me 
that  the  disease  which  most  frequently  gives  occasion  to  this  want 
of  sound,  is  not  that  now  under  consideration,  but  hypertrophy 
with  dilatation.      Corvisart's  observation  respecting  the  greater 

There  are  some  doubts  of  the  value  of  this  sign  as  indicating  a  dilatation  of 
the  cavities  of  the  heart.  This  clear  and  distinct  sound  which  Laennec  men- 
tions, seems,  in  fact,  in  some  cases  at  least,  to  be  only  a  modification  of  the 
sound  of  the  valves.  A  certain  degree  of  alteration  in  the  texture  of  the 
membranes  composing  the  valves  which  border  the  orifices  of  the  heart,  would 
be  sufficient  to  make  the  sound  clearer  or  louder.  Furthermore,  it  will  be  Been 
that  if  the  sounds  of  the  heart  are  occasioned  by  the  play  of  the  valves,  these 
sounds  will  become  louder  as  the  parietes  of  the  heart  become  thin  ;  and,  on 
the  contrary,  they  will  grow  dull  as  the  parietes  of  the  heart  thicken.— Andral. 


DILATATION    OF    THE    HEART. 


651 


degree  of  lividity  of  the  face  in  dilatation  of  the  heart,  is,  in  like 
manner,  perhaps,  not  quite  correct.  It  is,  no  doubt  true,  as  he 
observes,  that  this  color  is  deeper  in  dilatation  of  the  right  than 
of  the  left  cavities,  and  the  same  may  be  said  of  the  color  of  the 
extremities :  nevertheless,  I  have  frequently  seen  the  countenance 
very  pale  and  of  a  dirty  yellow,  and  the  lips  even  devoid  of  the 
natural  degree  of  color,  in  dilatation  of  the  heart ;  while,  on  the 
other  hand,  hypertrophy  with  dilatation  of  the  right  side,  has  ap- 
peared tome  to  be  the  affection  most  frequently  attended  with 
intense  lividity  of  the  face  and  extremities,  great  oppression,  fre- 
quent or  severe  haemoptysis  and  extensive  anasarca.* 

The  only  constant  and  truly  pathognomonic  sign  of  dilatation 
of  the  right  ventricle,  is  the  loud  sound  of  the  heart  perceived 
under  the  lower  part  of  the  sternum,  and  between  the  cartilages 
of  the  fifth  and  seventh  ribs  of  the  right  side.  The  degree  of 
dilatation  is  measured  by  the  extent  of  the  sound  of  the  heart 
over  the  chest,  and  according  to  the  scale  of  progression  formerly 
mentioned.!  The  palpitations  which  accompany  this  affection 
consist,  principally,  in  an  increase  of  the  frequency  and  sound 
of  the  contractions,  while,  at  the  time,  the  impulse  of  the  heart's 
action  is  frequently  feebler  than  in  the  ordinary  state  of  the  pa- 
tient. Irregularity  of  the  action  of  the  heart  as  to  force  and  fre- 
quency, and  the  intermission  of  pulse  attending  these,  are  un- 
usual, although  more  common  than  in  hypertrophy.^ 

*  With  the  more  important  general  signs  or  effects  of  dilatation  of  the  heart, 
viz.  serous  infiltration,  discoloration  of  the  face,  congestion  of  the  brain,  injec- 
tion of  the  mucous  membranes  and  passive  haemorrhage,  Dr.  Hope  has,  in  his 
treatise,  very  properly  noticed  congestion  and  enlargement  of  the  liver.  This, 
he  truly  says,  is  so  common  a  consequence  of  retardation  of  the  circulation  on 
the  right  side  of  the  heart,  that  few  persons  so  affected  in  any  considerable  de- 
gree are  exempt  from  it.  By  the  obstruction  which  it  occasions  in  the  system 
of  the  vena  porta  it  leads  to  ascites. —  Transl. 

t  I  have  met  with  some  cases  in  which  the  heart,  though  much  dilated, 
yielded  only  an  impulse  without  sound  or  with  a  very  dull  sound,  for  some  days 
before  death.  In  these  cases,  hypertrophy  was  combined  with  the  dilatation,  and 
the  enlarged  heart  seemed  confined  within  the  mediastinal  cavity.  The  sound 
was  further  obscured  from  the  co-existence  of  softening  of  the  heart,  and  dis- 
eases of  the  lungs. — Author. 

t  Bertin  makes  an  important  observation  respecting  the  symptoms  attending 
dilatation  of  the  heart,  and  which  should  always  be  kept  in  view.  As  this  af- 
fection usually,  if  not  always,  results  from  some  obstruction  to  the  course  of  the 
blood,  many  of  the  symptoms  attending  the  disease  are  the  consequence  of  the 
primary  obstruction  rather  than  of  the  dilatation.— My  own  observation  leads 
me  to  agree  with  M.  Laennec  in  regarding  the  swollen  state  of  the  jugulars 
without  pulsation,  as  a  very  frequent  sign  in  dilatation  of  the  right  ventricle  ; 
and  in  this  opinion  I  am  joined  by  Dr.  Hope  (Loc.  Cit.  p.  602.)— Among  many 
other  equivocal  symptoms  of  dilatation,  1  think  that  of  pain  or  rather  a  feeling  of 
distress  in  the  region  of  the  heart,  and  pain  extending  sometimes  to  the  top  of  the 
sternum,  between  the  shoulders,  or  left  arm,  deserve  notice.  These  symptoms, 
when  they  recur  in  paroxysms,  constitute  a  variety  of  angina  pectoris.  Among 
the  many  disorders  of  structure  and  function  occasioned  by  dilatation  of  the 
heart,  even  when  existing  only  in  so  slight  a  degree  as  not  materially  to  inter- 
fere with  the  business  of  life,  my  attention  has  been  particularly  called  to  head- 


652  DILATATION    WITH    HYPERTROPHY. 

CHAPTER  IV. 

OF    DILATATION    WITH    HYPERTROPHY    OF    THE    VENTRICLES. 

The  re-union  of  these  two  states,  which  constitutes  the  active 
aneurism  of  M.  Corvisart,  is  extremely  common ;  much  more 
common  than  simple  dilatation,  and  still  more  so  than  hyper- 
trophy without  dilatation.  This  complication  may  exist  in  one 
or  both  ventricles.  In  the  latter  case,  the  heart  acquires  a  pro- 
digious size,  sometimes  more  than  triple  that  of  the  hand  of  the 
individual.  The  augmentation  of  volume  is  here  the  effect  of 
thickening  of  the  walls  of  the  ventricles  and  proportional  en- 
largement of  their  cavities.  Their  muscular  substance  also  usu- 
ally acquires  a  greater  degree  of  solidity.  The  apex  of  the 
heart  becomes  blunter,  but  this  is  rarely  so  great  as  to  give  to 
the  organ  the  rounded  form  noticed  in  the  case  of  simple  dilata- 
tion. In  a  middling  degree  of  the  affection,  the  ventricles  are 
dilated,  and  their  walls  seem  only  not  to  be  thinner  than  natural, 
or  there  is  evident  hypertrophy  of  the  walls  without  diminution 
of  the  cavities.  In  some  rare  examples,  different  portions  of  the 
parietes  of  the  same  ventricle,  exhibit  the  character  of  hyper- 
trophy, and  others  that  of  dilatation,  as  has  been  truly  observed 
by  M.  Bertin. 

Signs. — The  signs  of  this  affection  are  a  compound  of  those  of 
hypertrophy  and  dilatation.  The  contractions  of  the  ventricles 
yield,  at  the  same  time,  a  strong  impulse  and  a  very  marked 
sound.  Those  of  the  auricles  are  also  sonorous.  The  sound  of 
the  heart's  action  is  heard  over  a  great  extent ;  and  sometimes, 
particularly  in  thin  subjects  and  children,  even  the  shock  is  per- 
ceptible below  the  clavicles,  on  the  sides,  and  even  a  little  on  the 
left  side  of  the  back.  In  the  case  of  a  woman,  who  labored 
under  this  affection,  I  heard  and  felt  the  contraction  of  the  ven- 
tricles at  the  lower  part  of  the  right  back  ;  and  although  this 
patient  was  of  a  small  stature  and  middling  strength,  the  impulse 
and  sound,  in  the  places  mentioned,  were  greater  than  in  the 
region  of  the  heart  in  the  case  of  a  strong  man  in  perfect  health.* 

ache ;  a  disease  which  I  think  I  can  trace  in  a  great  number  of  cases  to  this  con- 
dition of  the  heart,  as  its  exciting  cause.  In  instances  of  this  kind,  the  impulse 
of  the  organ  is  feeble,  but  its  sound  is  loud  and  audible  over  the  greater  part  of 
the  chest.  This  observation,  if  found  generally  correct,  is  of  great  practical 
importance.     The  rationale  of  the  case  is  sufficiently  obvious. — Transl. 

*  A  singular  case  of  pulsation  in  the  right  bypochondre,  in  a  case  of  dis- 
eased heart,  is  recorded  by  Mir.  Ward,  in  the  Med.  andPhys.  Journ,  No.  391 ; 
in  which  the  pulsation  was  owing  to  the  right  lobe  of  the  liver,  enormously  en- 
larged, extending  into  the  chest,  and  coining  in  contact  with  the  hem.  Many 
of  the  cases  of  pulsation  felt  very  remote  from  the  .heart,  may  be  explained  by 


DILATATION    WITH    HYPERTROPHY. 


653 


In  this  affection,  the  contractions  of  the  ventricles  are  very 
easily  perceived  by  the  hand ;  which  (particularly  during  palpi- 
tation) is  moreover  forcibly  raised  by  the  sharp,  definite,  and 
violent  pulsations.  Even  in  the  absence  of  palpitation,  if  we  at- 
tentively observe  the  patient,  we  frequently  perceive  the  head, 
limbs,  and  even  the  bed-clothes,  strongly  shaken  at  each  contrac- 
tion of  the  heart.  The  pulsations  of  the  carotid,  radial,  and 
other  superficial  arteries  are  frequently  visible.  If  we  press  on 
the  region  of  the  heart,  this  organ,  according  to  the  expression  of 
Corvisart,  "seems  to  be  irritated  by  the  pressure  and  beats 
more  forcibly  still."  To  these  energetic  contractions  of  the 
heart,  according  to  this  author,  corresponds  (when  the  disease 
affects  the  left  ventricle)  a  pulse  which  is  frequent,  strong,  hard, 
vibrating,  and  difficultly  compressed.  This  state  of  pulse 'is,  no 
doubt,  frequently  met  with  in  hypertrophy  with  dilatation,  as 
well  as  in  simple  hypertrophy  of  the  left  ventricle :  I  cannot, 
however,  consider  it  with  Corvisart,  as  a  sign  of  the  active  aneu- 
rism of  the  left  ventricle,  inasmuch  as  we  very  frequently  observe 
a  small  and  feeble,  although  regular  pulse,  in  subjects  whose  hearts 
are  much  enlarged  and  habitually  violent  in  their  action. 

The  palpitations  which  take  place  in  this  affection,  present 
under  the  stethoscope  the  same  characters  as  the  habitual  con- 
tractions in  the  same  case,  only  in  a  more  intense  degree :  they 
are  seldom  attended  with  irregularities,  except  on  the  approach 
of  death.  Sometimes,  during  these  palpitations,  besides  the 
impulse  of  the  heart,  which  seems  communicated  by  a  large  sur- 
face, we  can  distinguish  another  which  is  sharper,  clearer,  and 
shorter,  although  occurring  at  the  same  time,  and  which  seems 
to  strike  the  walls  of  the  chest  with  a  much  smaller  surface.  This 
blow  seems  evidently  occasioned  by  the  apex  of  the  heart. 

The  examination  of  the  actions  of  the  heart  first  on  the  one 
side  then  on  the  other, — that  is,  under  the  lower  part  of  the  ster- 
num and  between  the  cartilages  of  the  fifth  and  seventh  ribs  of  the 
left  side,  enables  us  to  ascertain  precisely  which  of  the  ventricles 
is  affected,  if  there  is  only  one ;  or  if  they  both  are  so,  which  is 
more  commonly  the  case.  Dilatation  with  hypertrophy,  being 
of  all  the  affections  of  the  heart,  that  in  which  this  organ  attains 
the  largest  size,  it  is  in  this,  accordingly,  in  which  the  absence  of 
the  natural  sound  on  percussion  of  the  cardiac  region,  is  observed 
most  frequently  and  most  extensively. 

the  intervention  of  a  conducting  medium  superior  to  that  which  naturally  exists 
in  these   situations;  although   this  result  arises   also  from  many   other  causes. 
■  Original  Cases,"  p.  137— 150.— Transl. 


654  DILATATION    WITH    HYPERTROPHY 


CHAPTER  V. 

OF    DILATATION    OF    ONE    OF    THE    VENTRICLES    WITH 
HYPERTROPHY    OF     THE    OTHER. 

This  species  of  complication  is  by  no  means  very  rare,  although 
it  is  more  so  than  the  preceding.  Its  signs  are  likewise  a  mix- 
ture of  those  of  hypertrophy  and  dilatation,  with  predominance 
of  the  one  or  other,  according  to  whichever  exists  in  the  greatest 
degree.  The  comparative  exploration  of  the  two  sides  of  the 
heart  is  a  certain  means  of  ascertaining  every  complication  of 
this  kind  that  can  take  place.  I  have  frequently  met  with  the 
following  varieties: — 1.  hypertrophy  with  dilatation  of  the  left 
ventricle,  and  simple  dilatation  of  the  right ;  2.  hypertrophy  with 
dilatation  of  the  left  ventricle,  and  simple  hypertrophy  of  the 
right ;  3.  hypertrophy  with  dilatation  of  the  right,  and  simple  di- 
latation of  the  left ;  4.  simple  hypertrophy  of  the  right,  with  dila- 
tation of  the  left :  this  last  is  the  rarest.  I  do  not  remember  to 
have  met  with  dilatation  of  the  right  ventricle  coinciding  with  sim- 
ple hypertrophy  (to  a  considerable  degree)  of  the  left ;  and  I  am 
even  inclined  to  consider  this  complication  as  almost  impossible, 
inasmuch  as,  in  the  case  of  great  hypertrophy  of  the  left  ventricle, 
the  right  seems,  as  formerly  observed,  as  if  hollowed  out  of  the 
walls  of  the  other.* 

Notwithstanding  what  has  been  above  stated  of  the  certainty 
of  the  evidence  supplied  by  mediate  auscultation  in  diseases  of  the 
heart,  it  must  be  admitted  that  it  will  always  be  those  diseases 
respecting  which  we  shall  be  most  liable  to  commit  grievous  errors 
in  diagnosis : — more  especially  if  we  restrict  our  exploration  to 
a  few  minutes,  and  fail  to  take  into  account  the  general  symp- 
toms and  diseases  that  may  complicate  those  of  the  heart.  For 
example,  trusting  to  the  stethoscope  alone,  if  applied  during 
a  moment  of  nervous  excitement,  we  might  be  led  to  conceive 
the  existence  of  dilatation  or  hypertrophy,  when  the  heart  was 
perfectly  sound  ;  whilst,  on  the  other  hand,  we  might,  under  cer- 
tain circumstances,  fail  to  discover  actual  disease  of  the  organ, 

*  The  following  synopsis  extracted  from  Dr.  Hope's  work  exhibits  the  various 
forms  and  combinations  of  hypertrophy  and  dilatation  of  the  ventricles,  and  in 
the  order  of  frequency  of  their  occurrence  : — 1.  Hypertrophy  wilh  dilatation  of 
the  left  ventricle,  and  a  less  degree  of  the  same  on  the  right;  2.  hypertrophy 
with  dilatation  of  one  ventricle,  especially  the  left,  with  simple  dilatation  of  the 
other  ;  3.  simple  dilatation  of  both  ventricles;  4.  simple  hypertrophy  of  the  left, 
and  hypertrophy  with  dilatation  of  the  right ;  5.  dilatation  with  attenuation  of  the 
left ;  6.  hypertrophy  with  contraction  of  the  left ;  7.  hypertrophy  with  contraction 
of  the  right. —  Transl. 


OF    THE    VENTRICLES. 


655 


although  existing  in  a  very  high  degree.  I  formerly  took  some 
notice  of  the  cases  in  which  such  errors  are  possible  ;  but  I  deem 
it  proper  to  renew  the  consideration  of  the  subject  in  this  place, 
as  such  errors  are  at  once  of  high  importance  and  very  easily  fal- 
len into. 

Dilatation  and  hypertrophy  of  the  heart,  are  in  their  essence 
mere  defects  of  proportion  between  this  organ  and  others,  or  be- 
tween some  of  its  own  constituent  parts ;  and  a  heart  which, 
from  its  great  size  alone,  is  a  cause  of  perpetual  distress  and 
eventually  of  death,  would  be  productive  of  no  inconvenience  if 
it  happened  to  be  lodged  in  a  thorax  of  somewhat  larger  capac- 
ity, and  belonged  to  an  individual  whose  lungs  and  capillaries 
were  of  a  somewhat  stronger  texture.  And,  indeed,  very  few 
persons  have  the  heart  in  exact  and  perfect  proportion,  either  as 
to  its  individual  parts  relatively  to  one  another,  or  in  its  relation 
to  the  size  and  strength  of  other  organs.  It  is  well  known,  that 
in  this  respect,  there  are  few  organs  possessed  of  such  variable 
proportions.  Generally  speaking,  it  is  better  that  the  heart 
should  be  rather  small  than  large  ;  but  all  those  whose  hearts 
are  rather  voluminous  do  not,  on  this  account,  always  suffer  from 
those  symptoms  which  constitute  what  is  called  disease  of  the 
heart,  more  especially  if  they  are,  in  other  respects,  strong  and  ro- 
bust. 

In  children,  more  particularly,  the  heart  is  perhaps  always  a 
little  larger  in  proportion,  than  in  the  adult ;  and  many  of  them 
exhibit  in  a  marked  degree,  the  stethoscopic  signs  of  hypertrophy 
or  dilatation,  or  more  commonly  of  both, — without  being  at 
all  diseased.  In  these  persons  the  equilibrium  is  restored  about 
the  period  of  puberty.  A  person  in  youth  or  manhood,  who  is 
otherwise  of  a  good  constitution,  may  be  affected  with  consider- 
able hypertrophy  or  dilatation,  without  experiencing  much  in- 
convenience ; — occasional  palpitations  of  little  severity  and  short 
duration,  and  a  slight  shortness  of  breath,  being  the  only  general 
indications  of  the  disease.  Among  the  lower  class  of  people, 
more  particularly,  the  individual  is  frequently  so  little  incom- 
moded by  the  affection,  that  he  pays  little  attention  to  it  and 
never  mentions  it  unless  questioned  on  the  subject.*  I  have  ob- 
served a  like  condition  of  the  organ  in  persons  affected  with  dis- 
eases of  other  parts  ;  and  when  these  last  have  proved  fatal,  I 
have  always  been  able  to  verify  by  dissection  the  accuracy  of  the 
stethoscopic  indications  respecting  the  state  of  the  heart.      In 

*  I  daily  meet  with  cases  of  ihis  kind,  which,  but  for  the  stethoscope,  would 
deceive  any  pfactioner.  Such  persons,  however,  are  marked  for  destruction. 
Alter  a  certain  time, the  disease  obtains  the  mastery,  and  "cuts  the  strongman 
down  ;"  and  the  sooner,  ulas  !  for  the,  bold  resistance  made  to  its  dominion. — 
Transl. 


656  DILATATION    AND    HYPERTROPHY 

cases  of  this  kind,  if,  from  the  effect  of  disease,  or  the  progress 
of  years,  there  happen  to  supervene  a  great  degree  of  emaciation 
and  loss  of  strength,  the  disproportion  between  the  heart  and 
other  organs  becoming  thereby  more  marked  (emaciation  being 
much  less  rapid  in  the  viscera  than  the  external  parts,)  the  gene- 
ral symptoms  of  diseased  heart  supervene.  A  delicate  woman, 
or  a  man  of  sedentary  habits  with  a  constitution  weakened  by  want 
of  exercise,  would  experience  in  a  much  shorter  period,  serious 
symptoms  from  a  like  degree  of  disproportion. 

For  these  reasons,  it  is  obvious  that  we  should  sometimes  fall 
into  error,  if  we  decided  from  the  stethoscopic  signs  alone,  that  a 
patient  labored  under  disease  of  the  heart.  But  the  knowledge 
thus  acquired  of  the  existence  of  a  large-sized  heart,  is  highly 
valuable,  even  although  the  individual  at  the  time  experiences 
no  inconveniences  from  it.  We  are  thereby  enabled  to  direct 
measures  for  diminishing  the  too  active  energy  and  nutrition  of 
the  organ,  and  thus  to  prevent  the  establishment  of  actual  dis- 
ease. This  is  a  matter  of  the  greatest  consequence,  as  it  is  a 
vast  deal  easier,  more  particularly  in  young  subjects,  to  effect  this 
object,  than  afterwards,  when  the  disease  is  formed,  to  interrupt 
its  progress  or  even  to  relieve  its  more  distressing  symptoms. 
And,  in  truth,  one  of  the  greatest  advantages  of  mediate  auscul- 
tation, is  the  facility  which  it  gives  of  recognizing,  not  merely  the 
slightest  degree  of  hypertrophy  or  dilatation  of  the  heart,  but  even 
the  simple  predisposition  to  these  diseases  ;  a  thing  altogether  im- 
possible, as  Corvisart  has  confessed,  by  the  sole  results  supplied 
by  the  pulse,  percussion,  and  the  state  of  the  functions. 

I  formerly  observed  that,  in  certain  cases,  the  contractions  of 
the  heart  entirely  lose  the  characters  which  announce  dilatation 
or  hypertrophy,  although  existing  in  a  very  great  degree.  These 
cases  are, — 1.  the  last  agony,  and  the  orthopncea  which  usually 
precedes  this,  for  some  days  or  even  weeks : — 2.  the  co-existence 
of  another  affection,  capable,  in  itself,  of  occasioning  great  dysp- 
noea, as  pneumonia,  cedema  of  the  lungs,  hydrothorax,  pleurisy 
with  considerable  effusion,  &c.  In  the  first  of  these  cases,  the 
impulse  and  sound  of  the  heart's  contractions  cease  almost  en- 
tirely, whatever  be  the  size  of  the  heart,  and  the  frequency  of  the 
contractions  becomes  so  great  that  these  cannot  be  counted.  Cor- 
visart had  taken  notice  of  this  almost  complete  disappearance  of 
the  perceptible  action  of  the  heart,  towards  the  close  of  its  dis- 
eases :  "  They  change  at  this  period  (he  says)  into  an  extended 
bruissement  and  an  obscure  and  profound  agitation  impossible 
to  be  described."  (Op.  Cit.  p.  141.)  In  the  second  case  above 
mentioned,  the  impulse  and  sound  of  the  heart  are  frequently  re- 
duced to  what  they  are  in  the  state  of  health  ;  and  if  then  exa- 
mined for  the  first  time,  they  give  no  clue  to  the  existence  of  the 


OF    THE    AURICLES. 


657 


hypertrophy  or  dilatation,  although  perhaps  existing  in   a  very 
eminent  degree. 


CHAPTER  VI. 

OF    DILATATION    AND    HYPERTROPHY    OF    THE    AURICLES. 

Dilatation  of  the  auricles  is  a  rare  disease,  and  it  appears  still 
more  so,  when  compared  with  the  frequency  of  the  same  affection 
of  the  ventricles.  Sometimes  we  find  in  subjects  affected  with 
hypertrophy  or  dilatation  of  the  ventricles,  the  auricles  also  pro- 
portionally enlarged  ;  it  is,  however,  much  more  common  to  find 
these  retaining  their  natural  size  even  in  cases  where  the  ventri- 
cles are  enormously  enlarged  ;  sometimes  also,  but  more  rarely 
still,  the  auricles  are  dilated  when  the  ventricles  are  of  the  natu- 
ral size. 

Before  we  can  judge  of  the  extent  of  this  affection  we  must 
have  precise  ideas  respecting  the  natural  proportion  of  the  va- 
rious cavities  of  the  heart.  As  far  as  the  cavities  are  concerned, 
we  must  admit  that  they  are  very  nearly  of  equal  size  ;  but  as 
the  walls  of  the  auricles  are  much  thinner  than  those  of  the  ven- 
tricles, the  former,  when  simply  full  and  not  distended,  compose 
only  about  one-third  of  the  whole  organ, — in  other  words,  the 
size  of  the  auricles  is  about  one-half  that  of  the  ventricles.  Both 
the  auricles  have  the  same  capacity,  although  some  anatomists 
have  considered  the  right  as  larger  ;  no  doubt  misled  by  its  flat- 
ter shape,  the  greater  length  of  its  sinus,  and,  more  especially, 
by  the  distended  condition  in  which  it  is  commonly  found  after 
death.  A  similar  distention,  though  more  rarely,  takes  place 
also  in  the  left  auricle  ;  and  this  accidental  and  temporary  en- 
largement is  sometimes  so  considerable,  owing  to  the  great  exten- 
sibility of  the  auricular  structure,  as  almost  to  equal  the  size  of 
the  ventricles.  In  order  to  distinguish  the  real  from  the  factitious 
dilatation,  we  have  only  to  empty  the  auricles  through  the  ves- 
sels that  enter  into  them,  when,  in  the  latter  case,  these  cavities 
will  immediately  resume  almost  their  natural  size,  and,  in  the 
former,  they  will  still  nearly  retain  their  acquired  volume.  There 
is  likewise  another  mark  by  which  we  can  at  once  discriminate 
the  enlargement  produced  by  the  accumulation  of  blood  during 
the  few  last  hours  of  life,  from  the  permanent  increase  of  capa- 
city of  the  auricles.  In  the  first  case,  the  walls  of  the  auricle 
are  greatly  distended  by  the  contained  blood,  and  the  color  of 
this  appears  through  the  thinnest  portions  :  while,  in  the  latter, 
S3 


658  DILATATION    AND    HYPERTROPHY    OF    AURICLES. 

the  auricles,  although  very  voluminous,  are  still  capable  of  con- 
taining more  blood,  and  their  parietes  remain  opaque. 

I  have  never  met  with  decided  dilatation  of  the  auricles  with- 
out some  thickening  of  their  walls ;  and,  on  the  other  hand,  I 
have  never  seen  thickening  of  their  walls  without  an  augmenta- 
tion of  their  capacity*  I  may  here  remark,  that  it  requires 
much  experience  to  judge  correctly  of  hypertrophy  of  the  auri- 
cles, as,  owing  to  their  being  naturally  very  thin,  a  considerable 
increase  (say  double  the  natural  thickness,  and  the  increase  is 
rarely  so  much)  is  not  obvious  to  a  person  little  accustomed  to 
such  examinations.  Bertin  (Op.  Cit.  p.  334)  met  with  a  case 
where  the  left  auricle  was  three  lines  thick. 

The  most  common  cause  of  dilatation  of  the  left  auricle  is  the 
contraction  of  the  orifice  between  it  and  the  ventricle,  in  conse- 
quence of  cartilaginous  or  bony  induration  of  the  mitral  valve, 
or  of  caruncles  on  its  surface.  The  same  causes  sometimes  oc- 
casion the  retraction  of  this  valve,  and  consequently  the  perma- 
nent patency  of  the  auriculo-ventricular  orifice.  In  this  case, 
dilatation  and  thickening  may  arise  from  the  mere  action  of  the 
ventricle  on  the  auricle.  Although  such  may  exist,  I  have  never 
seen  any  change  in  the  auricles  without  some  alteration  in  the 
valves.  Dilatation  of  the  right  auricle  is  most  commonly  the 
consequence  of  thickening  of  the  right  ventricle.  The  diseases 
of  the  lungs  which  M.  Corvisart  reckons  among  the  ordinary 
causes  of  this  dilatation,  seem  to  me  to  produce,  in  general, 
merely  the  accidental  distention  above  mentioned. 

Corvisart  does  not  make  any  distinction  between  the  signs  of 
dilatation  of  the  auricles  and  that  of  their  corresponding  ventri- 
cles. And,  in  truth,  such  affections  are  too  rare,  and  I  have 
had,  consequently,  too  few  opportunities  of  seeing  them  since  I 
practised  auscultation,  to  be  able  positively  to  assert  that  the 
signs  by  which  I  have  sometimes  been  enabled  to  recognize  them, 
are  quite  certain  and  constant.  I  think,  however,  there  can  be 
little  doubt  that  the  signs  afforded  by  dilatation  of  the  auricles, 
must  be  confounded  with  those  arising  from  the  disease  of  the 
ventricles,  or  of  the  valves,  of  which  the  auricular  affection  is  the 
consequence ;  and  that  thus  the  dilatation  of  the  left  auricle  will 
be  confounded  with'  ossification  of  the  mitral  valve,  and  that  of 
the  right  auricle  with  hypertrophy  of  the  ventricle  of  the  same 
side,     It  has,  moreover,  appeared  to  me,  that,  in  dilatation  of  the 

*  M.  Bertin  says  (p.  336)  that  he  has  seen  hypertrophy  of  the  auricles  under 
the  three  forms  observed  in  disease  of  the  ventricles ;  but  that  that  with  dila- 
tation of  the  cavity,  is  incomparably  more  frequent  than  the  others.  Dr.  Hope 
wives  the  following  as  the  order  of  frequency  of  the  different  forms  of  enlarge- 
ment of  the  auricles  : — 1.  Distention,  particularly  of  the  right,  from  congestion 
during  the  last  agony  ;  2.  dilatation  with  hypertrophy  ;  3.  simple  hypertrophy ; 
4.  hypertrophy  with  contraction. —  Transl. 


PARTIAL    DILATATION    OF    THE    HEART. 


659 


auricles,  whether  real  or  factitious,  their  contractions,  in  place  of 
the  clear  sound  which  they  have  in  the  healthy  state,  and  which 
I  have  compared  to  the  sound  of  a  valve,  yield  only  the  bellows- 
sound,  more  or  less  strong,  or  at  least  a  sound  that  is  dull.  I 
have  never  perceived  any  distinct  impulse  from  the  auricles,  even 
when  decidedly  hypertrophied.  I  ought  here,  also,  to  notice  a 
negative  sign,  formerly  mentioned  in  the  analysis  of  the  heart's 
pulsation.  It  is  this  : — In  many  cases  of  hypertrophy  of  the  ven- 
tricles, we  scarcely  perceive  the  sound  of  the  contraction  of  the 
auricles,  while  exploring  the  region  of  the  heart.  If,  however, 
we  apply  the  stethoscope  to  the  top  of  the  sternum,  below  the 
clavicles,  or  on  the  sides,  we  hear  the  sound  of  their  contraction 
very  distinctly,  and  often  very  loudly.  This  sign,  as  I  formerly 
mentioned,  appears  to  me  to  indicate  positively  that  the  auricles 
do  not  in  any  respect  participate  in  the  affection  of  the  ventricles. 


CHAPTER  VII. 

OF    PARTIAL    DILATATION    OF    THE    HEART. 

In  certain  cases,  the  heart  may  be  affected  with  a  partial  and 
truly  aneurismatic  dilatation.  M.  Corvisart  found,  in  the  per- 
son of  a  young  negro  who  died  from  suffocation,  an  example  of 
this  affection.  "  On  the  superior  and  lateral  part  of  this  ventricle 
(the  left)  there  was  a  tumor  almost  as  large  as  the  heart  itself. 
The  interior  of  this  tumor  contained  several  layers  of  coagulated 
blood,  very  dense,  and  exactly  like  those  found  in  aneurisms  of 
the  limbs. — The  cavity  of  this  tumor  communicated  with  the 
ventricle  by  a  small  opening,  smooth  and  polished."  (Op.  Cit. 
p.  283.)  A  similar  case  is  cited  by  M.  Corvisart  from  the  Mis- 
cell.  Nat.  Curios.  I  have  only  had  occasion  to  see  a  single 
case  of  this  kind,  and  this  I  owe  to  M.  Berard.  Since  that 
time,  this  gentleman  has  met  with  a  second,  and  he  has  given 
an  account  of  both  of  them  in  his  Inaugural  Dissertation*  In 
both  of  these  cases,  the  dilatation  was  in  the  inferior  portion  of 
the  left  ventricle,  was  of  a  globular  shape,  and  nearly  the  size 
of  a  duck's  egg.  A  sort  of  neck,  or  circular  depression,  dis- 
tinguished it  externally  from  the  upper  part  of  the  ventricles. 
In  the  first  case,  of  which  I  saw  the  preparation,  the  channel  of 
communication  between  the  left  ventricle  and  the  tumor  was 
more  than  an  inch  in  diameter.     The  interior  of  the  swelling  was 

*  Dissert,  sur  pleusicurs  points  d'Anat.  Pathol,  &c.     Paris,  1826 


660  PARTIAL    DILATATION    OF    THE    HEART. 

lined  by  half-dried  fibrinous  concretions,  of  a  yellowish  color, 
disposed  in  concentric  layers,  some  of  which  were  firm  and  others 
slightly  friable ; — in  a  word,  exactly  resembling  those  found  in 
the  sacs  of  aneurisms.  The  most  exterior  of  these  layers  were 
the  most  solid  and  these  adhered  so  firmly  to  the  walls  of  the 
aneurism,  that  it  was  impossible  to  separate  them  from  it,  without 
removing  at  the  same  time,  a  portion  of  the  muscular  substance 
of  the  heart.  This  intimate  adhesion  existed  even  in  the  point 
of  communication,  the  borders  of  which  were  somewhat  rough. 
On  the  left  side  of  the  sac,  the  continuity  of  the  fleshy  fibres 
of  the  heart  was  very  distinct ;  but  on  the  right  or  inner  side, 
in  which  place  the  tumor  projected  beyond  the  point  of  the 
right  ventricle  and  septum  more  than  the  thickness  of  the  finger, 
the  walls  of  the  sac  seemed  merely  composed  of  the  two  mem- 
branes of  the  pericardium  united  together  by  cellular  substance, 
and  by  the  fibrinous  layers  within.  M.  Berard's  second  case  dif- 
fered only  from  the  first  in  the  following  particulars  :  the  two 
layers  of  the  pericardium  were  here  united  over  the  surface  of  the 
tumor  only,  whereas,  in  the  first  case,  they  were  adherent  over 
their  whole  extent ;  the  fibrinous  concretions  were  softer,  conse- 
quently of  more  recent  formation  ;  and  there  co-existed  hyper- 
trophy with  dilatation  of  the  ventricle.*  The  general  aspect  of 
the  preparation  shown  me  by  M.  Berard,  leads  me  to  consider 
these  partial  dilatations  as  originating  in  ulcerations  of  the  in- 
ternal face  of  the  ventricles.  I  form  this  opinion  on  the  follow- 
ing grounds  : — the  decreased  thickness  of  the  muscular  substance, 
— the  intimate  union  between  it  and  the  layers  of  fibrine, — the 
complete  disappearance  of  all  fleshy  columns, — the  analogy  of  the 
case  with  the  false  consecutive  aneurism  of  the  arteries.  As 
hardly  any  information  could  be  obtained  respecting  the  history 
of  these  cases,  I  cannot  say  whether  the  stethoscope  is  likely  to 
give  any  sign  of  a  lesion  of  this  kind.f  The  same  may  be  said 
of  another  rare  species  of  dilatation  described  by  Morand,J   a 

*  In  the  celebrated  tragedian,  Talma,  who  died  of  a  disease  of  the  rectum, 
there  was  found  a  partial  dilatation  of  the  heart  precisely  like  those  described 
in  the  text.  "  In  the  left  ventricle  (says  M.  Biett)  there  was  an  aneurismal  sac 
of  the  size  of  a  small  egg,  filled  with  hard  fibrinous  layers,  and  of  which  the 
parietes  seemed  formed,  by  the  double  thickness  of  the  two  serous  membranes 
of  the  heart.    {Revue  Med.  Jan.  1827.)— (M.L.) 

t  Laennec's  opinion  of  the  origin  of  these  partial  dilatations  from  ulceration 
is  corroborated  by  a  case  mentioned  by  Dr.  Hope,  "  in  which  steatomatous  de- 
generation had  caused  the  formation  of  a  canal  from  the  aorta  underneath  one  of 
the  sigmoid  valves  and  the  internal  membrane  of  the  left  ventricle,  leading  to 
an  aneurism,  as  large  as  a  nut,  in  the  substance  of  the  auriculo-ventricular  sep- 
tum." In  this  case  the  physical  signs  were  not  noticed,  but  Dr.  Hope  adds, 
that  a  similar  case  occurred  subsequently  it  St.  George's  Hospital,  in  which  the 
second  sound  was  accompanied  with  a  bellows  murmur.— Treatise  on  the  Heart, 
286.— Transl. 

t  Hist,  de  l'Acad.  des.  Sc.  1729. 


PARTIAL    DILATATION    OF    THE    HEART.  661 

second  case  of  which  was  communicated  by  me  to  the  Soc.  de  la 
Faculte  de  Med  *  This  is  a  dilatation  formed  in  the  middle  of 
one  of  the  lips  of  the  mitral  valve,  resembling  a  thimble  or  glove- 
finger  projecting  into  the  auricle.  In  the  case  «een  by  me,  the 
little  pouch  projecting  from  the  upper  side  of  the  valve  was 
about  half  an  inch  long,  more  than  four  lines  wide,  and  was 
pierced  at  its  extremities  by  two  openings,  of  which  the  lowest 
was  the  largest.  This  last  was  irregular  and  fringed,  and  had 
the  appearance  as  if  the  lower  lamina  of  the  mitral  valve  had 
been  ruptured  in  this  point,  and  the  little  aneurismal  sac  had  been 
formed  by  the  dilatation  of  the  upper  lamina. 

There  is  still  one  other  variety  of  partial  dilatation  of  the  heart, 
which  I  have  several  times  met  with,  and  which  is  probably,  in  a 
great  measure,  the  result  of  original  malformation.  In  the  natural 
conformation  of  the  heart,  the  right  ventricle  seems  to  consist  of 
two  distinct  parts  united  together,  the  one  of  which  descends 
towards  the  apex,  while  the  other,  almost  at  right  angles  to  the 
former,  is  directed  to  the  left  side,  and  forwards  towards  the  pul- 
monary artery.  The  dilatation  to  which  I  now  allude,  seemed  to 
exist  in  both  these  divisions,  while  the  point  of  union  of  the  two 
retained  its  natural  dimensions.  It  is,  however,  more  common  to 
find  the  anterior  or  pulmonary  division  of  the  ventricle  dilated 
without  the  other  portion :  and  in  most  cases  of  dilatation  of  this 
ventricle,  the  former  portion  is  more  dilated  than  the  other.  This 
difference  becomes  still  more  evident  when  the  dilatation  is  con- 
joined with  a  certain  degree  of  thickening,  as,  in  this  case,  the 
pulmonary  portion  of  the  ventricle  frequently  acquires  such  a 
degree  of  firmness  that  its  walls  do  not  collapse  when  laid  open, 
a  thing  which  hardly  ever  happens  to  the  lower  portion  of  the 
ventricle.f 

*  Bulletin  de  la  Faculte  de  Med.  No.  14,  p.  207. 

+  In  the  preceding  remarks  Laennec  has  said  nothing  of  the  dilatation  which 
may  affect  one  of  the  orifices  of  the  heart — an  alteration  which  has  been  proved 
to  exist  in  more  than  one  instance.  Cases  have  been  known,  for  example, 
where  the  aortic  orifice  was  so  far  enlarged  that  the  valves  were  too  small  to 
close  by  their  elevation,  the  entrance  of  the  left  ventricle.  In  consequence, 
at  each  dilatation  of  this  ventricle,  a  portion  of  tho  blood  which  it  had  thrown 
into  the  aorta,  flowed  back.  There  is  one  of  the  causes  of  the  disorder  now 
known  by  the  name  of  Deficiency  of  the  valves  ( Insuffisance  des  valvules.)  of 
which  more  hereafter. — Andral. 


662  INDURATION    OF    THE    HEART. 

CHAPTER  VIII. 

OF    INDURATION*  OF    THE    MUSCULAR    SUBSTANCE    OF    THE    HEART. 

I  have  already  observed,  that,  in  hypertrophy  of  the  heart,  the 
muscular  substance  possesses  an  unusual  degree  of  firmness  and 
consistence.  Corvisart  has  seen  this  so  great,  that  the  heart 
sounded  like  a  dice-box  when  struck,  and  the  scalpel  experienced 
great  resistance  in  cutting  it,  and  produced  a  peculiar  creaking 
sound.  However,  the  muscular  substance  of  the  heart  "  retained 
its  natural  color,  and  did  not  appear  to  be  converted  either  into 
the  bony  or  cartilaginous  tissue."  I  had  been  long  of  opinion  that 
this  species  of  induration  is  extremely  rare,  having  never  met  with 
a  case  of  it,  although  Corvisart  says  that  he  had  seen  several. 
However,  in  the  year  1821,  while  examining  the  body  of  a  man 
who  had  died  of  simple  but  very  extensive  hypertrophy  of  the 
right  ventricle,  I  purposely  struck  this  ventricle  with  the  scalpel, 
and  found  that  it  produced  a  sound  exactly  resembling  what 
would  arise  from  striking  a  leathern  dice-box.#  I  have  since 
frequently  repeated  this  experiment,  and  have  ascertained  that 
the  ventricles  in  a  state  of  hypertrophy  always  yield  this  box- 
sound,  and  in  a  degree  proportioned  to  the  degree  of  the  hyper- 
trophy. I  have  never  observed  the  creaking  sound  mentioned 
by  Corvisart :  but  only  that  such  hearts  were  cut  with  greater  diffi- 
culty, although  the  muscular  substance  appeared  in  no  other  re- 
spect altered.  M.  Bertin  gives  three  cases  (Obs.  93,  94,  95)  of 
hypertrophy  with  strongly  marked  induration  of  the  heart.  Cor- 
visart imagined  that  this  state  of  induration  would  render  the  con- 
traction of  the  ventricles  more  difficult  and  would  impede  their 
motions.  I  cannot  assent  to  this  opinion,  since  I  have  always 
found  the  most  solid  hearts  to  be  those  which  gave  the  greatest 
impulse.  Neither  can  I  admit  with  M.  Bertin,  that  the  induration 
of  the  heart  may  be  considered  as  the  first  stage  of  the  ossifica- 
tion, since  there  exists  none  of  the  anatomical  characters  of  the 
transition  of  one  of  these  states  into  the  other.  Induration  usu- 
ally occupies  the  whole  of  one  ventricle,  while  ossification  affects 
only  a  small  portion  of  its  walls,  and,  as  we  shall  see  hereafter, 
rarely  attacks  the  muscular  substance.  If  to  these  reasons,  de- 
duced from  simple  observation,  we  wish  to  add  any  argument 
drawn  from  theory,  it  may  be  stated,  that  induration  supposes  an 
increase  of  nutrition,  and  ossification  a  perversion  of  the  nutritive 
action.f 

*  It  is  proper  to  observe  that  the  ventricle  had  been  emptied  of  its  blood.—  Au- 
thor. 

t  Otto  (Compend.  of  Pathol.  Anat.  Part.  II.  Sect.  xix.  p.  286.  South's  Transl.) 


SOFTENING    OF    THE    HEART.  "D<* 


CHAPTER  IX. 

OF    SOFTENING    OF    THE    MUSCULAR    SUBSTANCE    OF    THE    HEART. 

I  have  already  noticed  this  condition  of  the  heart.  It  is  recog- 
nized by  the  flaccidity  of  the  organ,  which,  at  first  sight,  looks 
as  if  withered  ;  and  it  is  found  to  be  easily  torn.  The  softening 
is  sometimes  carried  so  far  that  the  muscular  fibre  is  almost 
friable,  the  compressing  fingers  passing  easily  through  the  parietes 
of  the  ventricles.  In  this  case,  whatever  may  have  been  the 
patient's  disease,  the  heart  appears  only  half  filled  with  blood,  and 
flattened,  and  the  ventricles  equally  collapse  whatsoever  may  be 
their  varying  thickness.  This  affection  of  the  heart  is  almost 
always  attended  by  some  change  of  color  in  the  organ.  Some- 
times this  is  deeper,  and  even  quite  violet ;  and  this  is  particularly 
the  case  in  severe  continued  fevers.  More  commonly,  however, 
the  softening  of  the  heart  is  attended  by  a  striking  loss  of  color, 
so  as  to  resemble  the  palest  dead  leaf.  This  pale  or  yellowish 
tint  does  not  always  occupy  the  whole  thickness  of  the  heart ; 
sometimes  it  is  strongly  marked  in  the  central  portions,  and  very 
little  on  the  exterior  or  interior  surfaces.  Frequently  the  left 
ventricle  and  the  interventricular  septum  exhibit  this  appearance 
in  a  marked  degree,  while  the  right  ventricle  retains  its  natural 
color,  and  even  a  degree  of  firmness  greater  than  natural.  Again, 
we  sometimes  find  here  and  there  spots  of  the  natural  color  and 
consistence  in  hearts  which  are,  every  where  else,  much  softened 
and  quite  yellowish.  This  variety  of  yellowish  softening  is  par- 
ticularly observable  in  hearts  of  good  proportion,  and  in  those 
cases  where  dilatation  is  conjoined  with  a  slight  degree  of  hyper- 
trophy. It  is  also  found  in  simple  dilatation,  although  it  is  more 
common  to  find  this  state  accompanied  by  that  species  of  softening 
which  is  marked  by  an  augmentation  of  the  natural  color  of  the 
organ.  There  is  a  third  variety  of  softening  of  the  heart,  which 
witl  be  noted  in  another  place,  and  which  is  attended  by  a  pale 
white  color  of  the  muscular  substance.  In  this,  the  degree  of 
softening  never  reaches  that  of  friableness  ;  often  it  is  scarcely 
perceptible ;  but  the  parts  are  flabby,  and  the  walls  of  the  ven- 
tricles quite  fall  together  on  being  opened.  This  species  of  soft- 
ening usually  accompanies  pericarditis,  and  is  observed  only  in 
it. 

says,  that  he  has  several  times  found  "  general  inflammatory  hardening  of  the 
heart"  carried  to  so  high  a  degree,  that  the  muscular  substance  was  quite  hrm  and 
elastic.  He  says,  he  likewise  observed  the  same  in  the  case  of  a  cow  which  had 
a  needle  in  her  heart,  and  in  a  dog  that  died  of  carditis—  Transl. 


664  SOFTENING    OF    THE    HEART. 

Softening  of  the  heart  not  naving  hitherto  engaged  the  atten- 
tion of  practitioners,  and  being  almost  always  found  in  conjunc- 
tion with  other  diseases  of  this  organ,  it  becomes  very  difficult  to 
determine  its  degree  of  danger,  as  well  as  its  distinctive  signs.  I 
formerly  stated,  that  softening  of  the  heart  is  one  of  the  causes 
which  appear  to  me  to  render  the  sound  of  the  auricles,  and  even 
of  the  ventricles,  more  obtuse  than  natural ;  yet  never  so  much 
so  as  to  render  it  like  the  sound  of  the  file,  or  even  of  the  bellows. 
We  may  likewise  expect  to  meet  with  this  condition  of  the  heart, 
when,  in  cases  of  dilatation,  with  or  without  hypertrophy,  there 
have  been  long  and  frequent  attacks  of  suffocative  dyspnoea,  a 
long  and  painful  agony,  or  that  purple  condition  of  the  face  and 
extremities  for  a  long  period  before  death,  which  bespeaks  great 
congestion  of  blood  in  the  capillaries.*  It  would  seem  that  that 
species  of  softening  met  with  in  a  case  of  a  protracted  agony 
is  to  be  considered  as  an  acute  affection  :  it  is  rarely  general,  and 
commonly  affects  only  different  points  of  the  substance  of  the 
heart. 

On  the  contrary,  in  cases  where  the  heart  is  softened  and  yel- 
lowish throughout,  it  is  probable  that  the  affection  has  existed  for 
a  longer  time.  This  general  softening  of  the  heart  is  usually, 
perhaps  always,  accompanied  with  a  certain  degree  of  cachexy, 
even  when  it  exists  in  persons  otherwise  in  good  health,  and  even 
in  such  a  state  of  vigor  as  to  be  able  to  undergo  severe  bodily 
labor,  as  we  see  sometimes.  These  persons  have  a  pale  and 
yellowish  complexion  and  a  withered  skin ;  and  even  when 
they  become  affected  with  dilatation  or  hypertrophy,  which  is 
almost  always  the  case,  they  do  not  exhibit  that  swollen  and  livid 
state  of  the  face,  which  is  considered  as  one  of  the  most  constant 
of  the  general  signs  of  diseased  heart.  Their  lips  are  seldom 
purple,  and  still  more  rarely  swollen :  but,  on  the  contrary, 
almost  always  colorless.     When  the   heart  yields  only   a  slight 

*  I  have  many  times  dissected  bodies  of  patients  who  died  with  all  the 
symptoms  described  here  by  Laennec,  but  I  never  found  the  heart  softened. 
As  to  the  stethoscopic  signs  which,  in  the  subsequent  paragraph,  he  mentions 
as  indicating  the  existence  of  a  softening  of  the  heart,  they  are  yet  to  be  proved, 
and  I  much  doubt  whether  they  have  been  observed  by  him  a  sufficient  num- 
ber of  times  to  enable  us  to  depend  upon  thein  in  the  diagnosis  of  the  softening 
of  the  heart.  The  same  may  be  said  of  the  pale  and  yellowish  hue  and  fading 
of  the  skin,  which,  according  to  him.  are  the  attendants  of  this  disease,  but 
which  no  observer  will  ever  regard  as  a  sufficient  characteristic  of  its  existence. 
Whatever  he  affirms  in  this  chapter  of  the  symptoms  of  softening  of  the,  heart, 
I  look  upon  to  be  rather  theoretical  than  the  result  of  observation.  The 
symptomatology  of  this  disease  is  yet  to  be  determined.  The  dull  and  obtuse 
sound,  which  Laennec  informs  us  takes  the  place  of  the  normal  sound  at  each 
of  the  pulsations,  has  perhaps  been  imagined;  in  the  idea  that  the  muscular 
firbre  in  contracting  must  create,  by  a  loss  of  its  consistence,  a  sound  different 
from  that  of  its  normal  state.  But  what  becomes  of  this  notion,  if  the  sounds 
of  the  heart  depend,  not  upon  the  contraction  of  its  tissue,  but  simply  upon  the 
elevation  of  the  valves  ? — Andral. 


SOFTENING    OF    THE    HEART. 


665 


impulse  and  sound,  and  when  this  last  is  obtuse  and  dull,  during 
both  contractions,  we  are  led  to  presume  that  the  organ  is  softened, 
but  well  proportioned. 

When  softening  exists  along  with  dilatation  of  the  ventricles, 
the  sound  produced  by  the  contraction  of  these  cavities,  although 
loud,  is  yet  dull,  and  without  the  clearness  which  attends  common 
dilatation.  When  it  is  complicated  with  hypertrophy,  the  sound 
of  the  contraction  of  the  ventricles  is  so  obtuse  as  to  be  nearly  in- 
audible ;  and  in  extreme  cases,  the  impulse  of  the  heart  is  attended 
by  no  noise  whatever.  It  has  moreover  appeared  to  me,  that 
softening  of  the  heart  contributes  much  to  render  the  contraction 
of  the  ventricles  slower.  Sometimes,  however,  in  attacks  of  pal- 
pitation, a  heart  in  this  state,  and  which  had  habitually  only  a 
slight  shock  and  a  very  dull  sound,  all  at  once  will  resume  great 
energy,  and  for  several  days  continue  to  give  those  sharp  short 
contractions  which  have  been  compared  to  the  blows  of  a  mallet. 

In  respect  of  the  danger  attending  softening  of  the  heart,  I 
presume  that  it  will  vary  according  to  the  nature  and  degree  of 
the  accompanying  affection.  The  variety  of  softening  which 
accompanies  idiopathic  fevers,  does  not,  in  general,  present  any 
change  of  color  in  the  heart,  or  it  is  attended  with  a  deeper 
color  than  natural,  approaching  purple;  sometimes,  however, 
it  is  yellowish.  I  think  it  may  be  compared  to  that  adhesive 
softness  of  the  other  muscles,  often  observed  in  these  cases,  and 
which  is  also  accompanied  by  a  degree  of  redness  greater  than 
natural.  This  softening  of  the  heart,  as  well  as  the  analogous 
gluey  or  fishy  state  of  the  muscles,  is  particularly  observable  in 
putrid  fevers,  more  especially  when  these  exhibit  the  phenomena 
formerly  considered  as  marks  of  putridity;  viz.  livid  intumes- 
cence of  the  face,  softening  of  the  lips,  gums,  and  internal  mem- 
brane of  the  mouth,  black  coating  on  the  tongue  and  gums, 
earthy  aspect  of  the  skin,  distended  abdomen,  and  very  fetid  de- 
jections. I  cannot  assert  that  this  softening  of  the  heart  exists 
"in  all  kinds  of  continued  fevers,  but  I  have  met  with  it  constantly 
in  such  cases  as  I  have  attended  to ;  and  I  have  always  thought 
1  it  more  marked  in  proportion  as  the  signs  of  an  alteration  in  the 
fluids  were  more  evident.  Could  it  account  for  that  frequency 
of  pulse  which  exists,  sometimes  for  several  weeks,  in  convales- 
cence from  fevers,  although  the  patient  continues  to  regain  flesh 
and  vigor? 

M.  Bouillaud,  in  the  work  which  he  has  composed  in  conjunc- 
tion with  M.  Bertin,*  considers  softening  of  the  heart  as  a  con- 

I  attribute  this  opinion  to  M.  Bouillaud,  on  the  authority  of  M.  Bertin,  who 
informs  me,  that  every  thing  in  this  work  relative  to  the  influence  of  inflamma- 
tion in  the  development  of  the  organic  affections  of  the  heart  and   large  ves- 

84 


666  SOFTENING    OF    THE    HEART. 

sequence  of  inflammation ;  and  looks  upon  the  induration,  as 
well  as  the  increase  or  diminution  of  coloring  of  the  heart,  in 
the  same  point  of  view.  The  only  proof  brought  in  support  of 
this  opinion  is  this — that  the  muscles,  the  brain,  liver,  lungs, 
kidneys  and  spleen,  become  soft  when  affected  with  inflammation. 
In  respect  of  this,  I  would  remark,  that  the  reasoning  is  here  in 
a  circle ;  since  it  ought  to  be  previously  proved  that  the  softening 
of  these  organs,  when  existing  alone  and  without  pus,  is  the  con- 
sequence of  inflammation.  On  the  other  hand,  if  softening  of 
the  heart  is  the  consequence  of  inflammation,  this  inflammation 
must  be  either  some  degree  of  that  which  produces  pus,  or  one 
of  quite  a  different  kind,  and  having  no  tendency  to  produce  this. 
On  the  first  hypothesis,  softening  of  the  heart  is  so  common  an 
affection,  that  we  should,  sometimes  at  least,  find  it  arrived  at 
the  stage  of  purulent  infiltration :  but  this  state  I  have  never 
seen,  even  in  the  case  of  softening  that  has  reached  so  far  that 
the  muscular  substance  yields  between  the  fingers  like  paste  ;  the 
muscular  fibres  still  retain  their  form,  and  present  no  trace  of 
pus  in  their  interstices ;  and  I  am  not  aware  that  pus  has  been 
found  by  any  one  in  such  cases.*     If,  on  the  second  supposition, 

sels,  is   exclusively    M.  Bouillaud's.     This  gentleman  has  since   professed  the 
same  opinions  in  his  TraiU  de  VEncephalite.     Paris,  1825. — Author. 

The  views  of  M.  Bouillaud  on  this  point  should  be  studied  in  the  TraiU 
Clinique  des  Maladies  du  Caiur,  published  in  1835,  and  not  in  the  previous 
works  of  the  same  author  cited  by  Laennec.  I  shall  again  refer  to  his  views  of 
carditis.  Here  let  me  remark  that  the  softening  of  the  heart,  like  that  of  the 
other  organs,  appears  not  to  be  necessarily  connected  with  inflammation,  either 
antecedent  or  cotemporary.  I  regard  it  simply  as  an  unexplained  alteration  of 
the  nutritive  process  of  the  substance  in  question.  Such  is  also  the  opinion  of 
Laennec.  But  I  will  go  beyond  him,  and  allow  that  inflammation,  inasmuch 
as  it  disturbs  the  nutrition  of  the  tissues,  may  be  regarded  as  one  of  the  causes 
of  this  softening.  And  here  I  cannot  agree  with  Laennec,  when  he  says  it  is 
the  property  of  inflammation  to  augment  the  consistence  of  the  tissues  instead 
of  diminishing  it.  Many  facts  contradict  this.  The  lung,  when  inflamed  and 
when  the  parenchyma  is  not  infilt.ered  with  pus,  breaks  readily  under  the  finger. 
In  cases  of  acute  gastritis,  and  in  those  caused  by  an  irritating  poison  in  the 
stomach,  the  coats  of  this  organ  soften  in  such  a  manner,  that  they  may  be 
pulled  to  pieces  with  a  slight  exertion.  There  is  no  doubt  that  the  softening  of 
the  brain  is,  in  most  cases,  connected  with  encephalitis — such,  for  instance,  as 
is  produced  by  the  passage  of  a  foreign  body  through  the  brain.  Every  body 
knows  that  the  coats  of  the  arteries  under  inflammation  are  easily  torn  by 
applying  a  ligature.  Finally,  the  softening  of  the  layers  composing  the  trans- 
parent cornea  in  acute  ophthalmia  or  inflammation,  not  only  affects  the  conjunc- 
tiva, but  results  in  the  perforation  and  destruction  of  the  tissue  of  the  cornea. 
If  then,  this  softening,  like  any  other  nutritive  alteration,  occurs  without  its 
being  possible  to  show  that  the  tissue  attacked  by  it  has  been  previously  affected 
by  a  stimulation  which  has  drawn  to  it  a  greater  quantity  of  blood  than  com- 
mon, it  would  be  unreasonable  to  deny  that  the  parts  acutely  inflamed,  tend  in 
general  to  softening  and  decay.  Induration,  on  the  contrary,  arises  for  the  most 
part  only  from  chronic  inflammations.— Andral. 

*  In  a  striking  case  of  true  carditis  recorded  by  Dr.  Latham  (Lond.  Med. 
Gaz.  vol.  iii.  p.  118.)  the  muscular  substance  of  the  heart  was  found  softened, 
and  "innumerable  small  points  of  pus  oozed  from  among  the  muscular  fibres" 
of  both  ventricles. —  Transl. 


SOFTENING    OF    THE    HEART. 


667 


softening  of  the  heart  is  an  affection  of  such  a  nature,  that  it  tends 
neither  to  the  formation  of  pus,  nor  is  attended  by  local  pains, 
nor  any  of  the  local  and  general  symptoms  which  constitute  in- 
flammation ; — if  the  therapeutic  measures  found  beneficial  in  in- 
flammation, are  directly  the  reverse  of  those  which  the  state  of 
the  individuals  usually  affected  with  softening  of  the  heart  seems 
to  demand, — why  give  the  same  name  to  affections  so  different? 

Softening  of  the  heart  appears  to  me  to  be  a  disease  sui  gene- 
ris, produced  by  some  aberration  of  assimilation,  whereby  the 
solid  elements  of  the  tissue  diminish  in  proportion  as  those  which 
are  fluid  or  semi-fluid  increase.  All  the  muscles  become  soft,  in 
a  slight  degree,  in  many  acute  and  chronic  diseases  even  in  the 
course  of  a  few  days  ;  a  fact  which  we  can  prove  not  only  by 
dissection,  but  even  by  feeling  the  muscles  of  our  patients :  and 
this  change,  we  know,  ensues  without  any  sign  of  inflammation. 
In  the  case  of  convalescence,  the  firmness  of  the  muscles  fre- 
quently returns  very  speedily,  and  before  the  emaciation  is  quite 
gone  off.  In  the  inflammation  of  the  muscles,  on  the  other  hand, 
(a  very  rare  case,  except  in  surgical  affections,)  softening  is  not 
observed,  except  where  the  muscle  is  destroyed  by  suppuration  : 
one  or  two  lines  from  the  abscess,  the  muscular  substance,  more 
or  less  colored  according  to  its  degree  of  impregnation  with 
blood  or  with  liquid  or  concrete  pus,  is  more  or  less  solid,  and 
frequently  even  more  solid  than  natural.  If  the  muscular  sub- 
stance appears  softer  than  natural,  it  is  only  where  the  concrete 
pus  begins  to  soften  ;  and  it  is,  no  doubt,  owing  to  the  softening 
of  this  pus,  which,  in  the  muscles,  the  cellular  substance,  the 
parenchyma  of  the  lungs  and  other  organs,  as  well  as  the  surface 
of  membranes,  is  frequently  effused  in  a  concrete  form,  that  we 
are  to  attribute  the  dissolution  of  the  various  tissues  with  which 
it  is  combined.  I  consider  even,  that  we  ought  to  regard  it  as  a 
general  law  of  the  animal  economy,  that  all  soft  tissues  become 
indurated  in  consequence  of  true  inflammation,  that  is,  an  in- 
flammation tending  to  the  formation  of  pus ;  and  I  know  no 
other  way  in  which  we  can  define  inflammation  without  making 
it  synonymous  with  affection.  It  is  only  the  hard  tissues,  such 
as  bone,  cartilage,  and  the  fibrous  bodies,  which  become  softer 
during  inflammation,  in  consequence  of  the  presence  of  an  in- 
creased quantity  of  plastic  lymph  of  a  less  consistent  quality  than 
that  of  bone.  The  softening  of  the  heart  and  muscles,  is,  more- 
over, not  without  analogies  in  all  the  different  tissues  of  the 
system,  as  in  the  case  of  rickets,  the  white  softening  of  the  brain, 
the  softening  of  the  mucous  membrane  of  the  stomach  and  in- 
testines, which  is  frequently  transparent,  colorless,  and  jelly-like  ; 
which  last  Hunter  considered  as  the  effect  of  the  action  of  the 


(568  ATROPHY    OF    THE    HEART. 

gastric  juice,  and  of  which  Jaeger*  and  Cruveilhierf  have  re- 
cently published  instances.  These  various  cases  of  softening 
may,  it  is  true,  sometimes,  like  gangrene,  be  surrounded  by  a 
circle  of  inflammation  ;  but  most  commonly  the  softening  exists 
by  itself;  when  combined  with  inflammation,,  there  is  no  reason 
why  the  two  affections  should  be  confounded,  since  they  may 
exist  separately. 

Softening  of  the  heart  subsequent  to  severe  continued  fevers, 
appears  to  me  to  be  an  affection  of  little  consequence,  and  is 
easily  removed  by  a  tonic  regimen.  The  softening  which  accom- 
panies chronic  affections,  particularly  of  the  heart,  indicates,  in 
a  particular  manner,  the  use  of  bitters,  steel,  and  anti-scorbutics, 
unless,  indeed,  these  are  contra-indicated  by  the  principal  affec- 
tion. I  have  often  thought  that  this  softening  of  the  heart  was 
an  analogous  disposition  to  that  of  hypertrophy  or  atr6phy  :  so 
far,  at  least,  it  agrees  with  these,  in  being  the  product  or  a  simple 
alteration  of  the  nutrition  of  this  organ.  Tn  this  case  there  is 
no  evident  perversion  of  the  assimilative  process,  since  there  is 
no  accidental  formation.  For  this  reason,  it  seems  probable,  that 
when  the  heart  is  in  a  state  of  softening  and  hypertrophy  at  the 
same  time,  we  are  to  expect  most  benefit  from  the  debilitating 
mode  of  treatment ;  and,  on  the  other  hand,  if  the  heart  retains 
its  healthy  proportions,  we  ought  to  apprehend,  for  the  same  rea- 
son, and  more  than  in  any  other  circumstances,  the  supervention 
of  hypertrophy  and  dilatation,  in  consequence  of  the  decreased 
resistance  afforded  by  the  walls  of  the  heart. J 


CHAPTER  X. 


OF    ATROPHY    OF    THE    HEART. 


The  heart,  like   the  muscles  of  voluntary  motion,  is  clearly  sus- 
ceptible of  diminution  of  size,  and  loss  of  power,  from   the  in- 

*  Hufeland's  Journ.  May,  1811. 

t  Med.  Ecclairee  par  l'Anat.  Path.     Limoges,  1821. 

t  Preternatural  softness  of  the  heart  is  a  state  frequently  met  with  on  dissec- 
tion, and  the  precise  nature  and  causes  of  which  are,  I  think,  extremely  doubt- 
ful, and  probably  very  various.  For  instance  :  in  a  case  lately  under  my  care, 
in  which  the  principal  symptoms  were,  extremely  quick  but  not  impeded  respi- 
ration, great  anxiety,  strong  action  of  the  heart,  strong  and  rapid  pulse,  very 
slight  increase  of  the  natural  temperature,  and  no  pain, — the  only  diseased  ap- 
pearance that  could  be  found  after  death,  was  this  softening  of  the  muscular 
substance  of  the  heart.  The  only  thing  that  gave  relief  was  blood-letting,  and 
the  blood  was  extremely  buffy.  I  have  great  doubts  if  this  was  a  case  of  car- 
ditis; I  have  seen  precisely  the  same  appearances  after  death  without  any  of 
the  same  symptoms  during  life. — Transl. 


DISPLACEMENT    OF    THE    HEART.  vbJ 

fluence  of  all  those  causes  which  produce  emaciation.  This  effect, 
however,  is  less  remarkable  in  the  heart  than  in  other  muscles, 
and  does  not  become  perceptible  till  after  a  considerable  time. 
It  may  be  remarked  as  generally  true,  that  the  hearts  of  indivi- 
duals who  have  died  of  diseases  productive  of  great  emaciation, 
such  as  cancer  and  chronic  phthisis,  are  commonly  small ;  and 
in  examining  such  cases,  I  have  thought  that  I  could  recognize 
a  sort  of  withering  of  the  organ  indicative  of  its  loss  of  volume. 
From  this  circumstance,  I  am  led  to  consider  the  softening  of  the 
heart  (which  I  have  stated  to  exhibit  a  similar  appearance)  as  an 
approach  towards  atrophy,— unless,  indeed,  the  over-activity  of 
the  nutritive  process,  or  the  determination  of  too  much  blood  to 
the  organ  lead  to  dilatation.  The  facts  just  mentioned  furnish 
the  most  rational  indication  for  treating  hypertrophy  of  the  heart, 
as  they,  at  once,  afford  grounds  for  admitting  the  possibility  of  a 
cure,  and  point  out  the  best  means  of  effecting  it.  In  certain 
cases  of  chronic  pericarditis,  the  heart  seems  to  become  smaller 
in  consequence  of  the  long-continued  pressure  of  a  copious  extra- 
vasation into  the  pericardium.  M.  Bertin  reports  a  case  of  this 
kind.     (Op.  Cit.  obs.  66.)* 

I  do  not  think  that  diminution  of  the  size  of  the  heart,  can, 
in  any  case  be  considered  as  a  disease.  1  have  never  observed 
any  symptom  which  could  be  attributed  to  this  cause  ;  or  rather, 
all  those  persons  in  whom  it  was  found,  appeared  to  me  less  sub- 
ject than  usual  to  inflammatory  affections  and  disorder  of  the 
circulation.  I  may  remark,  however,  that  several  hypochondri- 
acs, who  were  liable  to  faintings  from  very  slight  cause,  gave,  under 
the  stethoscope,  signs  of  a  very  small  heart ;  and  we  know,  more- 
over, that  women  who  are  much  more  liable  to  these  attacks  than 
men,  have  in  general  smaller  hearts.f 


CHAPTER  XI. 

OF    DISPLACEMENT    OF    THE    HEART. 

The  heart,  although  retained   in  its  place  by  the  diaphragm, 
large  vessels,  and  peculiar  structure  of  the  mediastinum,  and  still 

*  I  have  found  the  heart  in  a  state  of  atrophy,  in  certain  cases  of  chronic 
pericarditis,  which  caused  thick  false  membranes  to  form  around  the  heart.  1 
have  also  found  atrophy  of  this  organ  in  other  cases  wheie  cancers  or  tubercles 
had  invaded  the  tissue.  Among  other  instances,  was  one  of  a  child  three  years 
old  who  had  a  thick  layer  of  tuberculous  matter  all  round  the  heart.  There 
was  hardly  a  vestige  of  the  fleshy  fibres  in  the  coats  of  the  right  ventricle. 

*  Diminution  of  the  size  of  the  heart  is  noticed  by  most  writers  on  diseases 
of  this  organ,  and  a  good  many  cases  of  it  are  given  by  Burns,  Testa,  Kreysig, 
Berlin,  &c.  See  in  particular,  Burns,  p.  109;  Testa,  vol.  iii.  p.  348  ;  and  Ber- 
tin, p.  387.—  Transl. 


670  DISPLACEMENT    OF    THE    HEART. 

more,  by  the  constant  state  of  plenitude  of  the  chest,  may  never- 
theless, in  certain  cases,  be  thrown  to  the  right  or  left  by  a  solid, 
liquid,  or  seriform  effusion  into  either  sac  of  the  pleura,  by  exten- 
sive tumors  in  the  lungs,  and,  as  we  have  already  seen,  by  emphy- 
sema of  this  organ.  In  like  manner  a  tumor  in  the  superior 
mediastinum,  or  a  large  aneurism  of  the  arch  of  the  aorta,  may 
press.it  downwards,  so  that  that  part  of  the  diaphragm  on  which 
it  reposes  shall  project  into  the  abdomen.  Sometimes  even  this 
depression  has  taken  place  without  any  visible  cause,  in  which 
case  the  affection  has  been  named  by  some  authors  prolapsus  of 
the  heart. 

When  the  heart  is  enlarged,  its  point  is  carried  to  the  left,  and 
the  auricles  to  the  right  side,  in  such  manner  that  it  comes  to 
lie  almost  transversely  across  the  chest.  This  observation  has 
been  made  by  M.  Bertin ;  (Op.  Cit.  p.  44 :)  and  I  have  myself 
often  proved  its  accuracy. 

These  various  kinds  of  displacement  produce  no  perceptible 
inconvenience  when  they  exist  in  a  slight  degree ;  when  more 
marked,  they  may  produce  bad  effects ;  but  in  this  case,  they  are 
themselves  consequences  of  lesions  much  more  serious.  Corvisart 
imagines  that  this  prolapsus  of  the  heart  is  always  the  effect  of 
considerable  dilatation  of  this  organ  and  that  it  occasions  acute 
and  continued  pains  in  the  oesophagus,  particularly  towards  the 
cardiac  extremity,  with  difficulty  of  deglutition,  pains  in  the 
stomach,  constant  disorder  of  the  digestive  functions,  and  nausea 
and  vomiting.  He  thinks,  moreover  that  in  this  case  the  action 
of  the  heart  is  perceived  much  lower  than  natural,  and  he  con- 
siders this  circumstance  as  one  of  the  chief  diagnostic  signs  of 
this  affection.  I  am,  however,  of  opinion  that  this  sign  is,  at 
best,  very  equivocal.  We  perceive  the  heart's  pulsation  in  the 
epigastrium  in  a  great  many  persons,  particularly  when  the  ster- 
num is  short,  although  the  heart  is  in  its  usual  position.  It  can 
be  only,  therefore,  in  subjects  whose  sternum  is  long,  that  we  can 
lay  any  stress  on  such  a  sign.  In  the  case  of  lateral  displace- 
ments, if  at  all  considerable,  they  will  be  readily  detected  by  the 
stethoscope ;  and  the  same  will  be  true  in  those  rare  cases  of 
transposition  of  the  viscera,  in  which  the  liver  is  on  the  left,  and 
the  heart  on  the  right  side.*     In  the  Ephem.  Nat.  Cur.  (vol.  x. 

*  A  case  under  my  observation  some  time  since  strikingly  demonstrated  the 
accuracy  of  the  statement.  A  patient,  in  the  clinical  wards  of  La  Charite,  had 
the  heart  pushed  towards  the  right  side  by  an  aneurismal  tumor  of  the  descend- 
ing aorta,  which  eventually  burst  into  the  left  sac  of  the  pleura.  In  this  case 
we  were  enabled,  by  means  of  the  stethoscope,  to  trace  accurately  the  progres- 
sive advance  of  the  heart  towards  the  right  side.  The  aneurism  lay  saddle-wise 
right  across  the  spine,  and  was  recognized  by  its  simple  pulsations  from  the 
period  of  the  patient's  admission,  viz.  three  months  nearly  before  death. — 
(M.  L.) 


MALFORMATION    OF    THE    HEART. 


671 


obs.  xxxix.),  there  is  a  case  in  which  the  heart  was  situated  per- 
pendicularly to  the  vertebral  column,  as  in  quadrupeds,  and 
without  any  trace  of  a  right  lung.  From  the  last-named  cir- 
cumstance it  seems  probable  that  the  case  has  been  inaccurately 
described.* 


CHAPTER  XII. 

OF    MALFORMATION    OF    THE    HEART. 

Deviations  from  the  natural  form  of  the  heart,  exclusively  of 
those  resulting  from  dilatation  or  hypertrophy  of  its  different 
parts,  must  almost  all  be  considered  as  monstrosites,  depending 
on  an  incomplete,  anomalous,  or  superabundant  development  of 
parts.  Many  varieties  of  these  have  been  taken  notice  of,  par- 
ticularly during  the  last  few  years  ;  and  I  shall  here  mention  such 
as  have  been  well  authenticated :  1.  The  foramen  ovale  unclosed 
after  birth.  This  is  a  case  so  common,  as  to  have  been  seen  by 
almost  all  pathological  anatomists.  2.  The  perforation  of  the 
septum  between  the  ventricles.  There  only  exist  a  few  cases 
of  this  ;  and  in  all  those  which  have  been  published,  as  far  as  I 
know,  the  opening  was  evidently  very  ancient,  and  appeared  to 
be  congenital.  It  is,  however,  possible  that  such  a  perforation 
may  be  produced  by  an  ulcer.  I  was  lately  presented  with  a 
heart  by  M.  Fouilhoux,  which  exhibited  an  opening  between  the 
ventricles,  capable  of  admitting  a  goose-quill,  and  extending  from 
beneath  one  of  the  laminae  of  the  tricuspid  valve  to  beneath  the 
origin  of  the  sigmoid  valves  of  the  aorta.  At  the  extremity  which 
opened   into  the   left  ventricle  it  was  smooth,   but  at  its  other 

t  LITERATURE  OF  DISPLACEMENT  OF  THE  HEART. 

Innumerable  cases  of  displaced  heart  are  on  record.  On  this  subject  I  particu- 
larly refer  to  the  learned  memoirs  on  this  subject  in  Testa,  (vol.  iii.  cap.  xviii.) 
and  Kreysig  (sect.  iv.  art.  ii.)  ;  to  the  short  chapters  on  the  same  subject  in  Ber- 
tin,  p.  441  ;  Hope,  p.  513,  and  to  the  following  dissertations  on  this  particular 
displacement. 

1671.  Hoffman,  (Fr.)     Cardianastrophe  admiranda.     Diss.     Lips.  4to. 
1723.  Martinez.     Obs.  rara  de  corde,  &c.     Madrit.  4to. 

1810.  Fleischmann.     De  vitiis  congenitis  circa  thoracem,  &c.     Erlang.  4to. 
1814.  Chaussier.     Note  sur  une  hernie   congen.  du   cceur  (Bull,  de   la  Fac.  de 
Med.)  Par. 

1817.  Zedler,  (J.  A.)     De  situ  cordis  abnormi.     Vratisl.  4to. 

1818.  Weese,  (K.)     De  cordis  ectopia.     Berl.  (with  engr.) 

1825.  Haan  (H.  J.)     De  ectopia  cordis  casu  illustrata.     Bonn.  4to.  (plates.) 

1826.  Breschet.     Memoire  sur  l'cctopie  du  cceur.  &c.  Par.  4to.  (with  plates.) 


C72  MALFORMATION    OF    THE    HEART. 

extremity,  and  within  the  septum,  its  surface  was  rough,  evident- 
ly ulcerated,   and  covered  with  fibrinous  crusts.     The   ulcerated 
portion  had  a  diameter  at  least  double  that  of  the  opening  into 
the  left  ventricle,  and  extended  about  three  lines  into  the  sep- 
tum,   forming   a  small    cul-de-sac    filled  with    fibrinous    concre- 
tions.    This  heart  had  yielded  the  bellows-sound  in  the  latter 
days  of  the  disease.     Dr.  Thibert,  some  years  since,  met  with  a 
similar  perforation,  near  the  junction  of  the  septum  of  the  au- 
ricles  and  ventricles,   disposed   in  such    manner   that   the    four 
cavities  of  the  heart   communicated    together   by  means  of  it. 
3.  The  foramen  ovale  and  ductus  arteriosus  have  been  found 
patent   at    the    same    time   by    Deschamps,    Fouquier,    Thibert, 
Monro,   and   Burns.     4.  Hunter    found   the    pulmonary   artery 
obliterated    at   its    origin,    so   as    to  receive    blood    only  by  the 
ductus  arteriosus.     5.  In   a  child  which  lived  seven   days,   the 
heart,  like  that  of  fishes,   had  only  one  auricle  and  one  ventricle, 
from  the  latter  of  which  the  aorta  and  pulmonary  artery  arose  by 
a  common   trunk.*     6.  The  aorta  originating  in  the  right,  and 
the  pulmonary  artery  in  the  left  ventricle.     7.  Wolff  and  Bres- 
chet  have  seen  respectively  a  case  in  which  there  was  only  one 
ventricle,  although  with  two  auricles.     The  subject  of  Wolff's 
case  lived  to  the  age  of  twenty-two  years.     8.  Bertin  the  elder 
found  the  arch  of  the  aorta  double  in  a  child  twelve  or  thirteen 
years  old :  "  the  aorta  arose  single  from  the  left  ventricle,  then 
divided  into  two  branches,  and  then    re-united  to   form  the   de- 
scending aorta,  like  the  two  arms  of  a  river  after  having  formed 
an  islet."     9.  The  aorta    originating  in   both    ventricles  at   the 
same    time.     This    malformation   has   been    seen   by    Sandifort, 
Scander,  Tielman,  and  Nevins.      10.  Dr.  Holmes  of  Canada."|:  has 
lately  related  a  case  in   which  the  right   auricle  of  the  size  of  a 
full  grown   foetus,  communicated   with  the  left  ventricle  in  place 
of  the  right.     The  ventricles  also  communicated  by  a  tendinous 
opening.     This  person  lived  to  the  age  of  twenty-one. 

The  valves  of  the  heart  may  likewise  exhibit  various  kinds  of 
malformation.  T  have  already  noticed  a  species  of  aneurismatic 
dilatation  of  the  mitral.  We  sometimes  also  meet  with  small 
oblong  smooth  openings  on  the  different  valves  of  the  heart ;  of 
this  I  have  seen  an  extensive  instance  on  the  tricuspid  valve,  con- 
stituting a  kind  of  net-work.§     The  following  seems  to  me  also 

*  Burns  on  the  heart,  p.  27.  The  Epfiem.  Nat.  Cur.  contains  two  similar  ob- 
servalions.     Dec.  i.  ann.  iv.  and  v.  obs.  40  ;  et  Dec.  ii.  ann.  obs.  44. 

t  Kreysig,  vol.  iii.  p.  200. 

|  Trans,  of  Med.  Chir.  Soc.  of  Edin.  vol.  i. 

§  The  valves  which  surround  the  arterial  orifices  of  the  heart  may  vary  in 
number  by  a  defect  of  conformation. 

I  lately  dissected  at  La  Charite  the  body  of  a  middle  aged  man,  in  which  the 
valves  of  the  pulmonary  artery  were  four  in  number;  three  of  a  size,  and  one 
smaller. — Andral. 


MALFORMATION    OF    THE    HEART-  673 

a  case  of  malformation-  which  I  observed  in  a  heart  affected  with 
hypertrophy  in  the  year  1823.  In  this  the  three  laminae  of  the 
tricuspid  valve  were  united  together  near  their  extremities,  but 
in  such  a  manner  as  to  leave  these  points  sufficiently  free  to  admit 
the  end  of  the  finger  between  them.  The  mitral  was  precisely 
in  the  same  state ;  and  contained,  moreover,  within  its  substance, 
some  small  cartilaginous  incrustations.  The  sigmoid  valves  of 
the  aorta  and  pulmonary  artery  were  in  like  manner  adherent 
to  one  another  for  the  space  of  about  one  or  two  lines,  at  the 
point  of  their  meeting.  The  valves  seemed  in  no  other  way  dis- 
eased, and  the  union  of  the  parts  was  so  intimate,  that  the  limits 
of  the  different  valves  could  not  be  distinguished.  The  bellows- 
sound  had  existed  very  distinctly  in  this  case,  on  both  sides  of 
the  heart.  We  may  fancy  that  the  appearances  noticed  in  this 
case  may  be  the  consequence  of  inflammation  in  the  foetus  ;  and 
yet  it  is  difficult  to  believe  that  the  coagulable  lymph  could  be 
so  accurately  confined  to  the  edges  of  the  valves,  as  that  no  other 
adhesion  or  thickening  should  have  been  produced  on  the  adjoin- 
ing parts.* 

In  a  practical  point  of  view,  these  various  kinds  of  malforma- 
tion may  be  reduced  to  one — the  unnatural  communication  be- 
tween the  cavities  of  the  heart ;  and  of  these,  by  far  the  most 
common  is  the  persistence  of  the  foramen  ovale.  Sometimes  this 
is  produced  by  the  imperfect  union  of  the  two  plates  of  the  foetal 
valve,  so  that  a  probe,  or  even  a  goose-quill,  can  be  passed  ob- 
liquely from  one  auricle  to  the  other.  This  condition  of  parts 
is  not  very  rare,  and  does  not  appear  to  be  productive  of  any 
kind  of  inconvenience.  In  other  cases  we  find  the  foramen  con- 
tinue constantly  open,  so  as  to  admit  the  finger.  I  have  myself 
seen  it,  in  a  subject  forty  years  old,  sufficiently  large  to  receive 
the  thumb.  It  is  commonly  believed  that  this  species  of  malfor- 
mation is  always  congenital ;  but  from  some  cases  which  I  have 
met  with,  I  am  disposed  to  believe  that  such  a  perforation  may 
be  produced  by  an  accident ;  or,  at  least,  when  such  a  condition 
of  parts  exists  as  above  described,  that  a  blow,  fall,  or  violent  ex- 
ertion, may  cause  the  dilatation  of  the  oblique  opening,  and  its 
progressive  enlargement.  The  history  of  several  cases  on  re- 
cord, especially  of  some  of  M.  Corvisart's  would  seem  to  con- 
firm this  opinion  ;  since,  in  several  of  these,  the  individuals  had 
enjoyed  good  health,  without  any  symptom  of  diseased  heart, 
until  they  had  experienced  some  of  the  accidental  causes  above 
mentioned. 

I  do  not  know  that  any  of  these  unnatural  communications  have 

*  A  case  exactly  like  this,  will  be  noticed  in  a  subsequent  note,  chap.  xix. 
Trans!. 

85 


674  MALFORMATION    OF    THE    HEART. 

existed  without  consequent  thickening  and  dilatation  of  either  the 
whole  or  part  of  the  heart,  especially  the  right  side.  This  may  be 
the  consequence,  either  of  the  too  stimulant  qualities  of  the  arte- 
rial blood,  or  rather  of  the  necessity  imposed  on  the  right  cavities 
(naturally  the  weakest)  of  a  more  energetic  action,  in  order  to 
resist  the  impulse  of  the  blood  flowing  from  the  left  side.  The 
symptoms  of  the  latter  affection  are,  consequently,  combined 
with  those  of  the  former.  These  are  principally  the  four  follow- 
ing: 1.  a  great  sensibility  to  the  impression  of  cold  ;  2.  frequent 
faintings  ;  3.  the  respiration  more  constantly  impeded  than  in 
most  other  diseases  of  the  heart :  and  4.  a  violet  or  bluish  co- 
lor of  the  skin,  much  more  extensive  than  in  any  other  disease, 
and,  sometimes,  even  general.  This  last  symptom  has  been 
named  by  several  authors  the  blue  jaundice,  the  blue  disease, 
or  cyanose.  It  is  to  be  observed,  however,  that  in  certain  dis- 
eases of  the  lungs,  particularly  emphysema,  the  blue  color  of 
the  skin  is  sometimes  as  considerable  and  as  general  as  in  this 
affection.  On  the  other  hand,  the  foramen  of  Botallus  has  been 
found  dilated  very  considerably,  without  there  being  present  any 
degree  of  lividity  except  in  the  face  and  extremities.  The  case 
of  extensive  dilatation  noticed  by  myself,  above  mentioned,  was 
of  this  sort. 

I  have  not  had  an  opportunity  of  studying  by  means  of  the 
stethoscope  the  peculiarities  presented  by  the  circulation  in  the 
case  of  malformation  of  the  heart.  I  presume,  however,  that 
such  exploration  would  not  supply  us  with  any  useful  diagnostic 
signs.  In  these  cases  the  two  sides  of  the  heart  contracting  at 
the  same  time,  and  being  both  full,  the  two  masses  of  blood  when 
coming  in  contact  will  not  give  rise  to  any  distinct  sound.  Cor- 
visart,  however,  says,  that  in  such  cases  the  hand  applied  to  the 
cardiac  region  perceives  a  kind  of  bruissement,  and  an  indescri- 
bable aggitation.  In  the  case  above  mentioned,  witnessed  by 
myself,  I  perceived  nothing  of  this  kind.* 

*  LITERATURE  OF  MALFORMATON  OF  THE  HEART. 

1802.  Meckel,  (J.  F.)  De  cordis  conditionibus  abnormis.     Halo:.  4to. 
1814.  Farre,  (J.  R.,  M.D.)    Pathological   researches.     Essay  I.     On    malforma- 
tion of  the  heart,  Lond.  8vo. 
1816.  Hein,  (J.  C.)  De  istis  cordis  deformationibus,  &c.  Goett.  4to. 
1824.  Gintrac,  (El.)  Obs.  et  rech.  sur  la  Cyanose.  Par.  8vo. 

1824.  Ramberg,  De  corde  vasisque  majoribus   eorundum  ratione  abnormi  in  ho- 

mine.  Bcrol.  8vo.  (with  eng.) 

1825.  Beckhaus,  (F.)  De  deformationibus  cordis  congenitis.  Besol. 

1826.  Louis  (P.  C.  A.)  De  la  communication  des  cavites  droites  avec  les  cavites 

gauches  du  coeur.   (Memoires  on  Recherches,  &c.)    Par.  8vo. 

1831.  Paget,  (J.,  M.D.)  On  the  congenital  malformations  of  the  heart.  Edin.  8vo. 

Burns,  p.  11 ;  Kreysig,  Band.  iii.  s.  100 ;  Bertin,  p.  431 ;  Hope,  p.  456 ;  And- 

ral,  (Precis.)  t.  ii.  p.  309;  Otto,  Part  II.  sect.    xix.  p.  267;  Meckel,  Handbuch, 

vol.  i. — Besides  the   above,  we  have   numerous   inaugural  dissertations  on  thfe 


OF    CARDITIS,    OR    INFLAMMATION    OF    THE    HEART. 


675 


CHAPTER   XIII. 

OF    CARDITIS,    OR    INFLAMMATION    OF    THE    HEART. 

Inflammation  of  the  heart  is  a  rare  affection,  and  is,  conse- 
quently, very  imperfectly  known,  both  in  a  practical  and  patho- 
logical point  of  view.  I  shall  here  notice  only  inflammation  of 
the  muscular  substance  of  the  organ.  There  are  two  varieties 
of  it ;  the  general,  or  that  affecting  the  whole  heart ;  and  tRe 
partial,  or  that  confined  to  a  small  extent  of  it.  There  perhaps 
does  not  exist  on  record  a  satisfactory  case  of  general  inflamma- 
tion of  the  heart,  either  acute  or  chronic.  The  greater  number 
of  cases  so  called,  and  particularly  those  given  by  M.  Corvisart, 
are  evidently  instances  of  pericarditis,  attended  by  that  degree 
of  discoloration  of  the  heart  which  we  shall  find  frequently  to 
accompany  that  affection.  Nothing  proves  that  the  paleness  of 
the  heart  in  such  cases  is  the  consequence  of  inflammation,  unless, 
indeed,  we  choose  to  consider  the  word  inflammation  as  synony- 
mous with  alteration  or  disease.  Inflammation  generally  increases 
both  the  redness  and  the  density  of  the  parts  which  it  occupies ; — 
but  the  discoloration  in  the  cases  alluded  to  is  conjoined,  in  ge- 
neral, with  a  perceptible  softening  of  the  heart.  It  is  further 
observable  that,  in  these  cases,  the  pericardium  was  filled  with 
pus,  while  not  a  particle  was  found  in  the  substance  of  the  heart 
itself:  now,  pus  must  be  considered  as  the  most  unequivocal 
indication  of  inflammation.  The  redness  and  injection  of  the 
capillaries  are  equivocal  signs,  inasmuch  as  they  may  be  pro- 
duced, even  in  the  dead  body,  by  gravitation,  and  as  they  com- 
monly appear  to  be  the  consequence  rather  of  the  state  of  things 
immediately  preceding  death,  than  of  any  actual  previous  disease. 
The  only  case  which  I  have  met  with  of  general  inflammation  of 
the  heart  possessing  this  unequivocal  mark,  is  noticed  by  Meckel 
in  the  Mem.  de  l'Acad.  de  Berlin,  for  1756  *     But  this  case  is 

disease  (Cyanosis,  the  blue  disease)  produced  by  the  intermixture  of  the  arterial 
and  venous  blood,  one  of  the  consequences  of  the  most  common  form  of  mal- 
formation. The  following  are  the  most  recent,  and  all  entitled  either  De  morho 
caruleo  or  De  Cyanosi :— Setter ,  Mterb.  1805;  Schulor,  (Enip.  1810;  Kaem- 
merer,  Halce,  1811;  Tobler,  Goett.  1812;  Haase,  Lips.  1813;  Hartmann,  Vien- 
na, 1817;  Marx,  Besol,  1820;  Zimmermann,  Besol.  1822;  Peters,  Kilice,  1822 ; 
Horner,  Monach.  1823  ;  D'AIton,  Ronna,  1824  ;  Meinecke,  Besol.  1825  ;  Lewes, 
Berol.  1824  ;  Ermel,  Lips.  1827.—  Transl. 

*  Since  the  publication  of  our  author's  Treatise  two  unequivocal  cases,  at  least, 
of  general  carditis  have  been  published  in  this  country,  one  by  Mr.  Stanley, 
(Med.  Chir.  Trans,  vol.  vii.)  the  other  by  Dr.  Latham  (Lond.  Med.  Gazette,  vol. 
iii.)  Mr.  Stanley's  case  was  a  complication  of  pericarditis  and  carditis,  but  the 
inflammation  of  the  muscular  substance  was  as  well  marked  as  that  of  the  serous 
membrane.     "  Upon  cutting  through  its  parictes,"  says  Mr.  Stanley, <;  the  fibres 


676  OF    CARDITIS,    OB 

described  jvith  so  little  precision,  as  merely  to  prove  the  possi- 
bility of  the  fact,  and  affords  no  help  towards  a  general  descrip- 
tion of  the  disease.  I  am  not  acquainted  with  any  undoubted 
example  of  gangrene  of  the  heart. 

Instances  of  partial  inflammation  of  the  heart  characterized 
by  the  presence  of  an  abscess  or  ulcer  in  its  parietes,  are  much 
more  common.  Benevenius  appears  to  have  been  the  first  that 
observed  an  abscess  in  the  walls  of  the  heart.  Bonetus  has  re- 
corded a  good  many  such  cases  in  his  Sepulchretum.  I  have 
only  met  with  one  instance  of  the  kind.  In  this  (in  a  child 
twelve  years  old)  the  abscess  was  situated  in  the  parietes  of  the 
left  ventricle,  and  might  have  contained  a  filbert :  it  was  compli- 
cated with  pericarditis.  In  another  case  of  a  man  sixty  years 
old,  I  found  an  albuminous  exudation,  of  the  consistence  of  boiled 
white  of  egg,  and  of  the  color  of  pus,  deposited  among  the  mus- 
cular fibres  of  the  left  ventricle.  The  patient  had  presented 
symptoms  of  an  acute  inflammation  of  some  of  the  thoracic  vis- 
cera, not  however  sufficiently  precise  to  indicate  its  particular 
site.*  Orthopnoea,  and  a  feeling  of  inexpressible  anguish,  had 
been  the  chief  symptoms.  In  the  actual  state  of  our  knowledge, 
it  seems  impossible  to  point  out  the  signs  of  abscess  of  the  heart. 
It  appears  that,  in  certain  cases,  this  may  exist  without  any 
marked  disorder  of  the  health.  The  subject  of  Benevenius's 
case,  was  a  person  who  had  been  hanged,  and  who  seemed  pre- 
viously in  good  health. 

were  exceedingly  dark  colored,  almost  of  a  black  appearance.  The  fibres  were 
also  very  soft  and  loose  in  their  texture,  being  easily  separable  and  with  facility 
compressed  between  the  fingers.  Upon  looking  closely  to  the  cut  surface  ex- 
posed in  the  section  of  either  ventricle,  numerous  small  collections  of  dark-col- 
ored pus  were  visible  in  distinct  situations  among  the  muscular  fasciculi.  Some 
of  these  depositions  were  situated  deeply,  near  to  the  cavity  of  the  ventricle, 
while  others  were  superficial  and  had  elevated  the  reflected  pericardium  from 
the  heart."  In  Dr.  Latham's  case  "  the  whole  heart  was  deeply  tinged  with 
dark-colored  blood  and  its  substance  softened ;  and  here  and  there,  upon 
the  section  of  both  ventricles,  innumerable  small  points  of  pus  oozed  from 
among  the  muscular  fibres.  This  was  the  result  of  a  most  rapid  and  acute  in- 
flammation, in  which  death  took  place  after  an  illness  of  only  two  days."  Even 
on  Laennec's  own  principles,  the  above  must  be  received  as  cases  of  general 
carditis;  but  there  can,  I  think,  be  little  doubt  that  he  is  too  rigid  in  excluding 
from  the  list  of  inflammatory  affections  of  the  muscular  substance  of  the  heart, 
several  other  cases  which  do  not  possess  the  same  decisive  test  of  pus.  It  is 
well  remarked  by  Dr.  Hope  that  few  will  concur  with  our  author  in  excluding 
softening  and  induration  with  increased  or  diminished  color,  from  the  signs  of 
inflammation  of  the  muscular  substance  of  the  heart.  "  These,"  says  Dr.  Hope, 
"  are  results  of  inflammation  in  other  muscles,  and  analogy  points  out  that  they 
have  the  same  origin  in  the  heart.  Further  evidence,  he  continues,  is  derived 
from  the  fact  that,  in  cases  of  pericarditis,  the  characters  in  question  sometimes 
occupy  only  a  certain  depth  of  the  exterior  surface  of  the  organ,  whence  the 
presumption  is  almost  positive  that  they  originate  in  an  extension  of  the  inflam- 
mation from  the  pericardium."     (Cyc.  of  Pract.  Med.  vol.iii.  p.  289.)— Transl. 

*  Andral  mentions  a  case  of  partial  abscess  of  the  heart,  very  like  Laennec's, 
ocurring  in  a  case  of  pericarditis.     (Precis  d'Anat.  Path.  t.  ii.  p.  324.)— Tra nsl. 


INFLAMMATION    OF    THE    HEART.  "77 

Ulcers  of  the  heart  have  been  still  more  frequently  observed 
than  abscess ;  they  have  been  met  with  in  its  external  and  inter- 
nal surface.*  All  the  cases,  however,  recorded  under  this  name 
are  not  quite  correctly  designated.  In  the  Sepulchretum  we  fre- 
quently find  a  case  of  pericarditis,  attended  with  a  rough  and  un- 
even pseudo-membraneous  exudation,  mistaken  for  an  ulcer  of 
the  exterior  surface  of  the  heart.  This  has  been  noticed  by 
Morgagni.  (Epist.  21  and  25.)  That  true  ulcers  of  this  surface, 
however,  have  been  observed,  is  beyond  doubt.  A  case  of  this 
kind  is  described  by  Olaus-Borrichius  in  the  following  words : 
"  Cordis  exterior  caro,  profunde  exesa,  in  lacinias,  et  villos  carneos 
putrescentes  abierat:"f  and  similar  cases  are  recorded  by  Peyerf 
and  Graetz.<§>  Ulcers  on  the  internal  surfaces  of  the  heart  are 
perhaps  more  common  than  on  the  external ;  or,  at  least,  there 
are  on  record  a  greater  number  of  incontestable  examples  of  the 
former.  Bonetus,  Morgagni,  and  Senac,  have  collected  a  great 
many  of  these. 

The  signs  of  ulcers  of  the  heart  are  as  obscure  as  those  of  ab- 
scess. Morgagni,  in  comparing  the  cases  of  this  kind,  published 
before  his  time,  remarks  that  the  symptoms  varied  in  every  in- 
stance, and  concludes  that  none  are  characteristic.  I  know  not 
that  auscultation  will  supply  us  with  any  that  are  more  certain  : 
and  I  confess  that  I  do  not  expect  that  it  will.  I  have  myself 
only  met  with  one  case  of  this  kind.  The  ulcer  was  on  the  in- 
ternal surface  of  the  left  ventricle,  and  was  an  inch  long  by  half 
an  inch  wide,  and  was  more  than  four  lines  deep  in  its  center. 
This  patient  had  labored  under  hypertrophy  of  the  left  ventri- 
cle, which  had  been  recognized  before  death :  but  the  stetho- 
scope gave  us  no  indication  of  the  ulcer,  nor  even  of  the  rupture 
of  the  ventricles  which,  judging  from  the  other  symptoms,  took 
place  two  days  before  death,  and  was  the  cause  of  this.|[ 

*  Morgagni,  Epist.  xxv.  No.  17.  et  seq.         t  Sepulchret.  lib.  ii.  obs.  86. 

t  Sepulchret.  sect.  ii.  obs.  21.  §  Disput.  de  Hydr.  pericard.  sect.  2. 

||  Carditis,  properly  so  called,  has  been,  until  very  recently,  confounded  with 
pericarditis  ;  and  indeed,  the  two  diseases  have  been  intentionally  so  confounded 
by  many  authors  :  it  is  for  this  reason  I  unite  their  bibliography. — Transl. 

Inflammation  of  the  heart  is  still  very  little  understood,  because  it  is  an 
uncommon  disease.  The  muscular  tissue  of  the  heart  in  this  relation  does  not 
differ  from  that  of  the  coats  of  the  other  hollow  vessels.  Nothing,  for  instance, 
is  more  uncommon  than  inflammation  of  the  fleshy  coat  of  the  stomach, 
the  intestines  or  tbe  bladder.  Gastro-enteritis,  like  cystitis,  consists  for  the 
most  part,  of  an  inflammation  of  the  mucous  membrane  of  these  organs  :  and 
beneath  this  membrane,  in  the  great  majority  of  cases,  the  muscular  membrane 
is  found  uninjured.  When  this  last  is  attacked  by  inflammation,  it  is  brought 
on  by  a  previous  irritation  in  the  mucous  membrane.  Reasoning  from  analogy, 
we  must  conclude  that  inflammation  in  the  heart,  as  elsewhere,  rarely  takes 
place  in  the  muscular  tissue.  It  would  follow  likewise,  that  in  the  heart  as  in 
the  other  organs,  this  inflammation  must  almost  always  be  limited  to  the  peri- 
cardium or  the  inner  membrane  of  the  heart,  and  that  it  must  have  originated 


678  OF    CARDITIS,    OR    INFLAMMATION    OF    THE    HEART. 

in  one  or  the  other  of  these  membranes  whenever  traces  of  it  are  found  in  tlir 
rieshy  parenchyma  of  the  heart. 

What  are  the  anatomical  signs  of  the  existence  of  carditis  ?  Of  the  number 
of  those  commonly  stated  by  medical  writers,  there  are  two  that  can  hardly  be 
relied  on:  namely,  the  uncommon  redness  of  the  heart,  and  its  softness 
Whenever  we  dissect  a  body  with  signs  of  putrefaction,  we  find  that  the  fleshy 
tissue  of  the  heart  has  lost  much  of  its  normal  consistence;  it  is  easily  torn, 
is  reddish,  as  are  the  inner  surfaces  of  the  cavities.  In  almost  every  case  where 
I  have  found  on  dissection,  this  redness  and  softness  of  the  heart,  other  circum- 
stances have  induced  me  to  regard  them  as  purely  the  effect  of  death  :  and  it  is 
very  rarely  that  I  have  been  led  to  think  them  the  result  of  inflammation.  As 
to  the  cases  of  softening  with  discoloration  or  yellowness  of  the  tissue  of  the 
heart,  they  are  still  more  difficult  to  explain.  The  clearest  cases  of  carditis  are 
those  where  pus  is  found  in  the  parenchyma  of  the  heart.  To  the  cases  of 
suppuration  of  this  organ  quoted  by  Laennec,  some  more  recent  may  be"aa"ded. 
M.  Simonet  mentions  an  individual,  aged  58,  who  entered  the  hospital  of  Beau- 
jon  with  the  symptoms  of  acute  rheumatism  of  the  joints  :  he  was  nearly  in  the 
agony  of  death  at  his  arrival,  so  that  the  symptoms  could  not  be  deliberately  noted  ; 
but  a  great  tumult  was  observed  in  the  pulsations  of  the  heart.  He  died  in  a 
state  of  syncope.  The  tissue  of  the  heart  was  found  to  contain  a  great  number 
of  purulent  collections.  The  tissue  was  in  general  very  friable,  and  of  a  yel- 
lowish grey  color.  This  was  a  case  where  the  alterations  of  color  and  consis- 
tence, coinciding  with  abscess,  appear  to  have  resulted  like  that,  from  inflam- 
mation.— Andral. 

LITERATURE  OF  CARDITIS  AND  PERICARDITIS 

1717.  Berger,  Diss,  de  inflammatione  cordis.      Wittcb.  4to. 

1759.  Heimann.  (A.  B.)  Diss,  de  perioardio  sano  et  morboso.     Leid.  4to. 

1742.  Hilscher,  (S.  P.)  De  exulceiatione  pericardii  et  cordis  (Haller,  Disp.  II.) 

1758.  Gloger,  Diss,  de  inflammatione  cordis  vera.     Jena. 

1775.  Pohl,  Pr.  de  pericardio  cordi  adhserente.     Lips. 

1773.  Nebel,  Pr.  de  pericardio  cum  corde  concreto.     Lcip. 

1788.  Nunn,  (M.)  diss  de  carditide  spontanea  (Doering  I.)     Erford. 

1789.  Metzger,  Diss,  de  carditide  (Doering  I.)     Regiom. 
1789.  Metzger,  Diss,  de  carditide.     Regiom. 

1807.  Gaulay,  (U.)  Memoire  sur  la  gangrene  du  cceur.     Par.  8vo. 

1808.  Davis,  (J.  F.,  M.D.)  An   inquiry  into  the   symp.  and   treat,   of  carditis. 

Bath. 
1810.  Lemazurier,  (M.  J.)  Diss,  sur  la  pericardite.     Par.  4to. 
1812.  Boullier,  (J   C.)  Diss,  sur  la  difficulte  du  diagnostic  de  la  pericardite.  Par. 
1813—1819.  Merat.  Diet,  des  Sc.  M.  (Art.  Cardite)  t.  iv.  (Art.  Pericardite)  t.  xl. 

Par. 
1817.  Hertzberg,  (G.  L.)  De  carditide,  Pt.  I.  and  II.     Halce. 
1819.  Roux,  Collectanea  quoedam  de  carditide  exudativa.     Lips.  4to. 
1819.  Huber,  (C.  U.  J.)  D.  de  carditide  qua?  epidemice  grassavit  &,c.   Grbning. 

8vo. 
1819.  Heim,  Von  der  idiopathischen  herzentzundung.  (Rustz.  Mag.  B.  vi.)  Berl. 

8vo. 

1819.  Gittermann,  Geschichte  einer  epid.  herzentzundung.     (Rhein.  Jahrb.  B. 

vi.) 

1820.  Roux,  (F.L.)  Comment,  de  carditode  exsudat.  (with  col.  engr.)  Lips.  4to. 
1821—1826.  Chomel.Dict.  de  Med.  (Art.  Cardite)  t.  iv.;  (Art  Pericardite)  t.  xvi. 
1822.  Dorn,  Beytrag  zur  diagnostik  der  herzentzundung.     (Hufeland's  Jourri.) 

Jan. 

1822.  Petrenz,  Diss,  de  pericarditidis  pathologia.     Lips.  4to. 

1823.  Tacheron,  (C.  F.)  Recherches  anat.  path.  (t.  iii.  Per icardite.)     Par.  8vo. 

1824.  Puchelt,  (F.  A.  B.)  De  carditide  infantum.     Lips.  8vo. 

1824.  Hope,  Cyc.  of  Pract.  Med.  (Art.  Pericarditis  and  Carditis)  vol.  iii.  Lond. 

1826.  Clas,  Ueber  Herzentzundung.      Wurtzb.  8vo. 

1826.  Krause,  (       )  D.  de  carditide  idiopathica  acuta.  Berol.  8vo. 

1828.  Stiebel,  Monographia  carditidis  et  pericarditidis  acuta;.     Franco/.  4to. 


RUPTURE    OF    THE    HEART. 


679 


1831.  Horn,  Encycl.  Worterb.  (Art.  Carditis)  B.  vii.     Berl. 

1832.  Davis,  (J.  F.,  M.D.)  A  second  inquiry  respecting  pericarditis  or  rheuma- 

tism of  the  heart.     Bath.  12mo. 
See  also  Morgagni,  ep.  24,45:   Lieutaud,  Anat.  Med.;  Portal,   Cours  d'Anat. 
Med.;  Frank,  Prax,   Med.   Univ.;  Baillie,  Morb.   Anat.;  and  the  treatises  of 
Corvisart,  Testa,  Burns,  Bertin,  and  Hope  on  disease  of  the  heart. —  Transl. 


CHAPTER  XIV. 


OF    RUPTURE    OF    THF    HEART. 


This  terrible  and,  fortunately,  very  rare  accident,  is  almost 
always  the  result  of  ulceration  of  the  ventricular  parietes.  Mo- 
rand  has  collected  several  cases  of  this  kind  in  the  Mem.  de 
1'Acad.  des  Sciences  for  the  year  1732  ;  and  Morgagni  has  de- 
scribed a  similar  instance.  (Epist.  27.)  Rupture  of  the  heart 
from  violent  exertion,  without  previous  ulceration,  is  much  rarer 
still  ;  and  the  number  of  incontestable  examples  of  this  is  very 
small.  Several  cases,  recorded  as  such,  are  so  imperfectly  de- 
scribed, as  to  leave  a  doubt  whether  the  alleged  rupture  might 
not  have  been  rather  the  consequence  of  the  incisions  of  an  in- 
expert dissector.*  And  more  frequently  still,  even  in  the  most 
recent  cases,  the  affection  is  too  imperfectly  described  to  make  us 
certain  that  the  rupture  was  not  the  consequence  of  ulceration. 
The  best  authenticated  examples  of  this  kind  of  rupture  are  those 
given  by  Haller  (Elem.  Physiol.)  and  Morgagni.     (Epist.  27.) 

It  is  surprising  that  the  extreme  thinness  of  the  parietes  of  the 
ventricles,  in  the  cases  of  accumulation  of  fat,  does  not  give  rise 
to  rupture,  more  especially  towards  the  apex  and  posterior  part 
of  the  right  ventricle.  This  is,  however,  so  far  from  being  the 
case,  that  ruptures  of  the  right  ventricle  are  much  rarer  than 
those  of  the  left ;  and  that,  in  this  last,  the  rupture,  when  it  oc- 
curs, is  very  rarely  towards  the  apex,  which  is,  nevertheless,  the 
point  where  its  walls  have  the  smallest  degree  of  strength  and 
consistence.  The  rupture  of  the  auricles  in  consequence  of  vio- 
lent efforts,  and  without  previous  ulceration,  has  been  observed 
still  more  rarely  than  that  of  the  ventricles.  Two  instances,  how- 
ever, are  recorded  in  the  work  of  M.  Bertin,  p.  50.  In  one  of 
these  cases  the  rupture  was  produced  by  a  fall ;  in  the  other  it 
occurred  without  any  perceptible  cause  :  the  heart  was  enormously 
loaded  with  fat.  Portal  knew  an  instance  of  rupture  of  the  vena 
cava  superior  where  it  joins  the  auricle,  in  a  young  woman  who 

*  Mistakes  of  this  kind  may  be  easily  avoided,  since  no  incision  made  after 
death  will  fill  the  pericardium  with  coagulated  blood,  as  is  always  the  case  in 
true  rupture  of  the  heart. — Author. 


680  RUPTURE    OF    THE    HEART. 

died  suddenly  in  a  cold  bath  ;  (Anat.  Med.,  t.  iii.  p.  355.)  and  in 
the  Ephem.  Cur.  Nat.  (Dec.  iii.  Ann.  iii.  obs.  82,)  there  is  a  case 
of  rupture  of  the  right  auricle  and  vena  cava  in  consequence  of 
external  violence. 

M.  Corvisart  has  given,  for  the  first  time,  examples  of  another 
species  of  rupture  of  the  heart,  of  a  less  certainly  dangerous 
nature ; — that,  namely,  of  the  tendons  and  fleshy  pillars  of  the 
valves.  (Obs.  33,  40,  41.)  In  the  three  cases  related  by  him 
the  rupture  appears  to  have  been  the  consequence  of  violent 
efforts.  A  sudden  and  very  intense  feeling  of  suffocation  was  the 
immediate  result  of  this  accident,  which  terminated  in  exhibiting 
all  the  usual  symptoms  of  diseases  of  the  heart.  In  a  subsequent 
chapter  (on  Excrescences  on  the  Valves)  a  case  will  be  detailed 
in  which  the  rupture  of  the  tendons  of  the  pillars  appears  to  have 
been  the  consequence  of  ulceration.  Bertin  (Obs.  31.)  has  seen 
rupture  of  one  of  the  pillars  of  the  mitral  valve,  occasioned  by 
violent  fits  of  coughing. 

Rupture  of  the  auricles,  ventricles,  and  large  vessels  within 
the  pericardium,  is  not  always  followed  by  sudden  death.  In 
several  cases  the  blood  accumulated  in  the  pericardium  formed  a 
solid  coagulum,  which  checked  for  a  time  the  haemorrhage.  Such 
a  result  would  especially  obtain,  if  the  relative  size  of  the  heart 
and  pericardium  were  such  as  to  render  a  great  effusion  of  blood 
impracticable.  M.  Cullerier  saw  an  instance  of  rupture  of  the 
left  ventricle,  in  which  the  wound  was  blocked  up  by  a  fibrinous 
concretion.  (Journ.  de  Med.  Sept.  1806.) — These  various  kinds 
of  rupture  can,  at  most  be  suspected  in  some  cases,  but  cannot 
be  certainly  recognized  by  positive  signs.  It  would  seem  possi- 
ble that  the  morbid  action  of  the  mitral  valve,  after  the  rupture 
of  its  pillars  might  afford  some  signs  by  the  stethoscope.  The 
severity  of  the  symptoms,  in  such  cases,  must  be  very  variable, 
according  to  the  extent  and  place  of  the  lesion.  The  rupture 
of  all  the  tendons  of  a  pillar  must  occasion  much  disturbance  in 
the  circulation.  The  complete  rupture  of  a  pillar,  or  its  separa- 
tion at  its  root,  must  occasion  still  more  serious  effects,  in  conse- 
quence of  its  floating  about  in  the  ventricles  almost  like  a  foreign 
body.  But  the  rupture  of  one  or  two  tendons  only  ought  not  to 
occasion  very  severe  or  permanent  symptoms.* 

Apoplexy  of  the  heart,  an  affection  which  I  am  surprised  has  not  been  men- 
tioned by  Laennec,  and  of  which  several  examples  have  been  recently  published 
by  M.  Cruveilhier,  (Anat.  Path.  3.  Liv.  Par.  1829,)  appears  to  be  much  more 
frequently  than  inflammation,  the  cause  of  rupture  of  the  heart.  This  lesion 
has  hitherto  been  observed  only  in  the  walls  of  the  left  ventricle  when  in  a 
state  of  hypertrophy.  Here,  as  in  the  case  of  other  muscles,  the  boundaries  of 
the  apoplectic  deposit  are  formed  partly  by  the  muscular  fibres  ruptured  and 
partly  by  their  simple  displacement.  When  quite  recent,  these  deposits  contain 
merely  coagulated  black  blood  ;  when  they  have  existed  some  days,  their  walls 
are  of  a  blackish  red  which  penetrates  to  a  greater  or   less  depth,  and    we  can 


RUPTURE    OF    THE    HEART.  "°1 

distinguish  some  shreds  of  muscular  fibres  amid  the  blood;  still  later  the  con- 
tained fluid  assumes  the  color  of  wine-lees,  and  appears  as  if  formed  of  an  ad- 
mixture of  blood  and#pus;  and  at  last,  it  becomes  entirely  purulent,  and  the 
walls  of  the  abscess  are  lined  by  false  membranes.  M.  Rousset,  whose  thesis  I 
had  occasion  to  notice  in  the  chapter  on  Pulmonary  Apoplexy,  (Reck.  Anat.  sur 
Us  hemorrhagits,  Par.  1827,)  has  recorded  a  very  fine  case  of  muscular  apoplexy, 
nearly  universal,  in  which  the  heart  was  the  site  of  three  deposits,  in  the  vari- 
ous stages  just  enumerated.  These  sanguineous  or  puro-sanguineous  depositions 
in  the  walls  of  the  heart,  usually  terminate  in  perforation  either  inwards  into  the 
cavity  of  the  ventricle,  or  outwards  into  the  pericardium.  In  the  latter  case 
their  rupture  is  almost  always  immediately  fatal.  In  the  former  case,  the  cavity 
becomes  filled  with  the  ventricular  blood,  and  eventually  the  remaining  exterior 
wall  of  the  abscess  being  distended,  gives  rise,  in  all  probability,  according  to 
the  ingenious  explanation  of  M.  Cruveilhier  (Diet,  de  Med.  Pract.  t.  iii.  Art. 
JipopJcxie)  to  those  partial  dilatations  of  the  heart,  described  by  M.  Breschet  un- 
der the  name  of  false  consecutive  aneurisms  of  the  heart,  and  of  which  two  cases 
by  M.  Berard  were  noticed  in  Chap.  VII.  of  the  present  Book.  M.  Reynaud, 
however,  in  a  notice  of  a  particular  kind  of  aneurism  of  the  heart,  (Journ.  Hebd. 
de  Med.  t.  ii.  p.  363,)  has  attempted  to  show  that  these  excavations  in  the  walls 
of  the  left  ventricle  are  sometimes,  in  reality,  the  result  of  a  partial  dilatation, 
they  having  been  observed  to  be  lined  (according  to  him)  with  a  membrane 
continuous  with  that  of  the  natural  lining  of  the  ventricle.  But  in  the  cases  ad- 
duced in  support  of  this  opinion  by  M.  Reynaud,  it  is  observable  that  the  lining 
membrane  of  the  aneurismal  sac  was  thickened  around  the  orifice  of  communi- 
cation between  it  and  the  cavity  of  the  ventricle  ;  a  circumstance  which  alone 
suffices,  in  my  judgment,  to  prove  that  the  membrane  lining  the  aneurismal  sac 
was  not  a  continuation  of  that  of  the  ventricles,  but  an  old  adventitious  mem- 
brane analogous  to  those  which  line  fistula?  in  ano,  and  are  continuous  with  the 
mucous  membrane  of  the  rectum.  In  this  point  of  view,  then,  the  case  of  M. 
Reynaud  differs  in  no  essential  respect  from  those  of  MM.  Cruveilhier  and  Rous- 
set, being  merely  an  example  of  the  manner  in  which  the  apoplectic  abscess  of 
the  heart  became  cicatrized.  All  the  cases  of  rupture  of  the  heart  hitherto  pub- 
lished, appear  to  me  to  confirm  the  opinion  that  cardiac  apoplexy  is  the  most 
common  cause  of  them.  It  is  proper  to  state,  however,  that  M.  Rachoux,  who 
appears  to  have  carefully  examined  the  same  facts,  gives  a  preference  to  the  ex- 
planation of  the  phenomenon  by  means  of  a  softening  of  the  heart ;  (Diet,  de 
Med.  t.  xvii.  Art.  Rupture;)  and  yet  when  we  consider  that  in  the  opinion  of 
this  gentleman,  every  apoplexy  is  preceded  by  softening,  we  may,  after  all,  con- 
sider his  opinion  as  not  being  essentially  different  from  that  of  M.  Cruveilhier. 
Respecting  the  opinion  of  M.  Cruveilhier,  that  apoplexy  never  affects  the  walls 
of  the  right  ventricle,  and  that  when  rupture  of  them  takes  place,  it  depends  on 
an  atrophy,  a  fatty  degeneration,  or  a  gelatinous  softening  of  the  heart,  I  am  not 
prepared  to  say  how  far  it  is  well  or  ill  founded.  The  recorded  facts  appear  to 
justify  it  no  farther  than  by  this  consideration— That  the  rupture  of  this  ventri- 
cle being  infinitely  more  rare  than  that  of  the  left,  it  seems  to  indicate  a  differ- 
ent cause. — (M.  L.) 

Rupture  of  the  heart  occurs  much  more  frequently  in  old  than  in  young  per- 
sons. Out  of  nineteen  cases  collected  by  Dr.  Townsend,  (Cyc.  of  Pract.  Med. 
Art.  Rupture  of  the  Heart,)  all  the  patients  were  above  sixty  years  of  age,  except 
one  of  fifty-eight.  It  would  likewise  appear  to  be  much  more  prevalent  in  the 
male  than  in  the  female  sex,  as  out  of  twenty-five  cases  noticed  by  the  same  au- 
thor, sixteen  were  men.  The  experience  of  all  pathologists  confirms  the  asser- 
tion of  Laennec,  that  rupture  of  the  heart  occurs  much  more  frequently  in  the 
left  ventricle  than  in  any  other  situation. 

The  following  synopsis,  which  I  have  drawn  from  the  writings  of  Morgagni, 
Ploucquet,  Testa,  Bertin,  Rostan,  Blaud,  Otto,  and  from  cases  published  by  Ad- 
ams, Townsend,  &c.  <&c,  gives  a  view  of  the  seat  of  the  lesions  in  fifty-seven 
cases :  ,( 

Left  Vent.         Right  Vent.         Both  Vent.     Right  Aur.         Left  Aur. 
32.  13.  3.  7.  2. 

All  these  cases  occurred  spontaneously,  or  after  slight  exertion,  except   ten,  of 
86 


682  ACCUMULATION    ABOUT    THE    HEART. 

which  number  six  were  the  immediate  consequence  of  blows  on  the  chest,  (wo 
occurred  during  coitus,  one  in  a  fit  of  epilepsy,  and  one  in  an  epileptic  parox- 
ysm. Of  the  cases  from  blows,  three  had  the  rupture  in«he  right  ventricle,  two 
in  the  left  ventricle,  and  one  in  the  right  auricle  ;  of  the  two  cases  from  coitus, 
one  was  in  the  right,  the  other  in  the  left  ventricle,  and  this  was  also  the  result 
in  the  two  other  cases. 

LITERATURE  OF  RUPTURE  OF  THE  HEART. 

1680.  Bohn,  (J  )  De  renunciatione  vulncrum.     Lips.  8vo. 

1731.  Salzmann,   (J.)  De   subitanea  morte   a  sanguine   in   pericardium    cfTuso. 

Urgent. 
1733.  Morand,  Mem.  de  l'Acad.  Roy.  des.  Sc.  1732.     Par. 
1764.  Mummsen,  Diss,  de  corde  rupto  (with  eng.)     Lips. 
1769.  Ludwig,  (C.  G.)  De  dextra  cordis  auricela  rupta.  (Ad.  Med.  Pr.  I.)  Lips. 

8vo. 
1788.  Murray.  Diss,  de  corde  rupto.     Upsal.  4to. 

1803.  Olmi,  (A.)  Mem  di  una  morte  repentina  cagionata  dalla  rottura  del  cuore. 

Fir. 

1804.  Pohl,  De  ruptura  cordis  (with  eng.)     Lips.  4to. 

1808.  Brera,  Diuna  straordinaria  rottura  di  cuore.     Verona.  8vo. 

1820.  Rostan,  (L.)    Mem.  sur   les  ruptures   du  coeur.    (Nouv.  Journ.    de   Med.) 

Par.  8vo. 
1820.  Blaud,  Memoire  sur  les  ruptures  du  cceur.  (Bibliotheque  Med.  Aout.)  Par. 
1820.  Patissier,  Diet,  des  Sc.  Med.     (Art.  Rupture  du  Caiur.)  t.  49.     Par. 
1823.  Rochoux,  (L.)  Diss,  sur  les  ruptures  duoceur.     Par. 
1827.  DesormeauxJDict.de  Med.  (Art.  Rupture.)  t.  17.     Par. 
1834.  Townsend,  Cyc.  of  Pract.  Med.  (Art.  Rupture  of  the  Heart.)\o\.  iv.  Lond. 
Morgagni,  De  caus.  et  sed.  morb.  Ep.  26,  27.  64. 

A  very  great  number  of  single  cases  of  rupture  of  the  heart  are  recorded  by 
authors,  a  considerable  part  of  which  are  noticed  in  the  memoirs  above  quoted, 
or  referred  to  in  the  Bibliotheca  of  Ploucquet  ( Corruptum)  and  in  the  elaborate 
notes  to  Otto's  Pathological  J]natom,y,  Part  II.  Sect.  xix. —  Transl.' 


CHAPTER  XV. 


OF    THE    ACCUMULATION    OF    FAT    ABOUT    THE   HEART,    AND    OF 
FATTY    DEGENERATION    OF    THIS    ORGAN. 

In  medical .  writings  we  find  many  examples  of  the  heart  being 
overloaded  with  fat  in  a  surprising  manner,  to  which  condition  of 
the  organ  various  symptoms,  and  even  the  sudden  death  of  the 
individuals,  were  attributed.  M.  Corvisart  thinks  that  an  enor- 
mous accumulation  of  fat  around  the  heart  may,  in  fact,  produce 
such  effects,  although  he  has  met  with  no  permanent  derange- 
ment of  any  kind,  in  persons  whose  hearts  were  found  to  be  much 
loaded  in  this  manner.  I  have  also  met  with  a  great  many  cases 
of  hearts,  similarly  overloaded,  in  subjects  who  had  died  of  various 
diseases.  In  these,  the  fat  was  deposited  between  the  muscular 
substaace  of  the  heart  and  the  investing  pericardium,  and  chiefly 
at  the  union  of  the  auricles  and  ventricles,  at  the  origin  of  the 


ACCUMULATION    ABOUT    THE    HEART. 


683 


great  vessels,  and  along  the  tract  of  the  coronary  arteries,  also 
along  the  two  edges  and  at  the  apex  of  the  heart.  Sometimes  the 
posterior  face  of  the  right  ventricle  is  covered  by  this  deposition 
in  its  whole  extent ;  a  circumstance  which  rarely  has  place  on  the 
surface  of  the  left  ventricle. 

The  fatter  the  heart  is,  the  thinner,  in  general,  are  its  walls. 
Sometimes  these  are  extremely  thin,  being  reduced  almost  to 
nothing,  especially  at  the  apex  of  the  heart  and  the  posterior  side 
of  the  right  ventricle.  On  examining  ventricles  affected  in  this 
manner,  they  present  the  usual  appearance  internally ;  but  on 
cutting  into  them  from  without,  the  scalpel  seems  to  reach  the 
cavity  without  encountering  almost  any  muscular  substance,  the 
columnae  carnae  appearing  merely  as  if  bound  together  by  the 
internal  lining  membrane.  •  In  these  cases  the  fat  does  not  appear 
to  be  the  product  of  degeneration  of  the  muscular  fibres,  as  these 
can  be  separated  by  dissection.  Sometimes,  indeed,  portions  of 
fat  penetrate  deeply  between  the  muscular  fibres ;  but,  even  in 
this  case,  the  distinction  between  the  two  tissues  is  still  very 
marked,  and  they  are  confounded  by  no  mutual  gradation  of 
color  and  consistence.  It  would  seem  probable  from  this,  that, 
from  pressure  or  some  unknown  aberration  of  the  powers  of  nutri- 
tion, the  muscular  substance  has  wasted  in  proportion  as  the 
investing  fat  has  increased.  It  might  be  reasonable  to  expect 
rupture  of  the  heart  from  an  affection  of  this  kind ;  such  an  in- 
stance, however,  has  never  occurred  to  me.*  Very  commonly  we 
find,  in  such  subjects,  a  large  quantity  of  fat  in  the  lower  part  of 
the  mediastinum,  particularly  between  the  pericardium  and 
pleura.  This  fat,  much  reddened  by  its  small  vessels,  and  covered 
by  its  pleura,  assumes  a  gross  resemblance  to  the  figure  of  a  cock's 
comb,  and  is  firm.  The  fat  surrounding  the  heart,  on  the  con- 
trary, is  almost  always  of  a  pale  yellow  color,  and  is  only 
of  moderate  consistence.  I  have  not  observed,  nor  yet  has 
M.  Corvisart,  any  symptoms  that  could  directly  denote  the 
existence  of  an  accumulation  of  this  sort.  I  apprehend  it  must 
exist  in  a  very  great  degree  before  it  gives  rise  to  any  serious 
complaint.  This  is  not,  therefore,  the  condition  I  wish  to  denote 
by  the  name  of  Fatty  degeneration  of  the  Heart. 

Fatty  degeneration  of  the  heart  is  an  actual  transformation  of 
the  muscular  substance  into  a  substance  possessing  all  the 
chemical  and  physical  properties  of  fat.  It  is  precisely  similar 
to  the  fatty  degeneration  of  the  muscles  observed  by  Haller,!  and 
Vicq-d'Azyr.J     I  have  only   met  with  it  in  a  small  portion  of  the 

*  In  several  of  the  cases  of  rupture  recorded  by  authors,  the  heart  was 
prodigiously  fat.  See,  for  instance,  one  of  Morgagni's  cases,  Ep.  xxvii.  ;  one  of 
M.  Berlin's  cases,  p.  50;  and  two  cases  by  Adams,  in  the  Dub.  Hosp.  Rep.  vol. 
iv. —  Transl. 

t  Opusc.  Pathol.      .  t  Tom.  v.  Edit,  de  Moreau. 


684  INDURATION    OF    THE    HEART. 

heart  at  one  time,  and  only  towards  the  apex.  In  these  portions 
the  natural  red  color  is  superseded  by  a  pale  yellow,  like  that 
of  a  dead  leaf,  and  is,  consequently,,  nearly  the  same  as  that 
of  certain  states  of  softening  of  the  heart.  This  change  of  struc- 
ture appears  to  proceed  from  without  inwards.  Near  the  internal 
surface  of  the  ventricles,  the  muscular  texture  is  still  very  distin- 
guishable ;  more  externally,  it  is  less  so;  and  still  nearer  the 
surface  it  becomes  gradually  confounded,  both  in  color  and  con- 
sistence, with  the  natural  fat  of  the  apex  of  the  heart.  In  such 
cases,  however,  even  the  portions  that  still  retain  most  of  the 
muscular  character,  when  compressed  between  two  pieces  of 
paper,  still  grease  these  very  much.  This  character  distinguishes 
this  species  of  degeneration  from  simple  softening  of  the  organ. 
I  have  never  found  rupture  of  the  "heart  attributable  to  this 
change,  any  more  than  to  the  morbid  accumulation  of  fat.  It  is 
denoted  by  no  symptoms  with  which  I  am  acquainted.* 


CHAPTER  XVI. 

OF     CARTILAGINOUS      OR     BONY     INDURATIONS      OF      THE      MUSCULAR 
SUBSTANCE    OF    THE    HEART. 

I  have  never  met  with  ossification  of  the  muscular  substance  of 
the  heart,  and  only  a  small  number  of  examples  of  this  are 
on  record.  M.  Corvisart  found,  in  the  case  of  a  man  who  died 
of  hypertrophy  of  the  left  ventricle,  the  whole  apex  of  the  heart, 
and,  more  partially,  the  columnae  carnas  of  the  left  ventricle  con- 
verted into  cartilagcf     (Op.  Cit.  p.  171.) 

Haller  (Opusc.  Pathol.)  found,  in  a  child,  whose  heart  was  of 
the  natural  size,  the  inferior  part  of  the  right  ventricle,  the  most 
muscular  parts  of  the  left  auricle,  and  the  sigmoid  valves  of  the 
aorta  and  pulmonary  artery,  in  a  state  of  ossification.  Filling, 
in  the  case  of  an  asthmatic  subject,  met  with  ossification  of  one 
of  the  fleshy  columns  of  the  left  ventricle.J     M.  Renauldin  has 

I  stated  in  the  last  note  (p.  681)  M.  Cruveilhier's  opinion  that  rupture  of 
the  right  ventricle  may  be  owing  to  the  fatty  degeneration  of  the  muscular  sub- 
stance ;  it  is  proper,  however,  to  observe  that  he  has  adduced  no  example  of 
the  sort,  and  of  the  facts  formerly  noticed,  there  is  not  one  calculated  to  bear 
out  this  opinion,  except,  perhaps,  that  of  M.  Grateloup.—  (M.  L.) 

t  In  a  female  who  died  with  ascites  at  the  hospital  Cochin,  I  found  the  heart 
in  the  following  condition  :  throughout  a  great  portion  of  the  inter-ventricular 
septum,  as  also  in  some  other  parts  of  the  walls  of  the  heart,  the  ordinary 
fleshy  tissue  was  replaced  by  a  white  firm  substance,  closely  resembling  acci- 
dental fibrous  tissue,  and  especially  that  of  uterine  tumors.  Small  masses  of 
cartilage  existed  in  different  parts  of  the  tissue .—Andral. 

t  Hufeland's  Journ.  B.  xv  p.  155. 


INDURATION    OF    THE     HEART. 


685 


published,  in  the  Journal  de  Med.  for  January,  1816,  a  very 
interesting  case  of  the  same  kind.  The  patient  was  a  man  thirty- 
three  years  of  age,  much  addicted  to  study,  and  subject  to  violent 
palpitations  on  the  slightest  motion.  "  On  applying  the  hand  to 
the  region  of  the  heart  a  sort  of  motion  of  the  ribs  was  felt,  and 
even  the  slightest  pressure  produced  very  acute  pain,  which  lasted 
long  after  the  pressure  was  discontinued.  On  examining  the  body 
after  death  the  heart  was  found  extremely  hard  and  heavy.  On 
attempting  to  cut*  the  left  ventricle,  great  resistance  was  found, 
owing  to  the  total  conversion  of  the  muscular  fibre  into  a  sort  of 
petrifaction,  having  in  some  places  a  sandy  character,  in  others 
a  resemblance  to  saline  crystalization.  The  grains  of  this  species 
of  sand  were  very  contiguous  to  each  other,  and  became  larger 
towards  the  interior  of  the  ventricle.  They  were  continuous  with 
the  columnse  carnae,  which  were  themselves  converted  into  a 
similar  substance,  but  still  retained  their  original  form,  only  much 
enlarged.  Some  of  these  sabulous  concretions  were  of  the  size  of 
the  point  of  the  little  finger,  and  resembled  small  stalactites 
shooting  in  different  directions.  The  ventricle  was  thickened. 
The  right  ventricle  and  great  arterial  trunks  were  sound.  The 
temporal  and  maxillary  arteries,  and  also  a  part  of  both  the  radial 
arteries,  were  ossified."  In  the  case  of  a  subject  with  ossification 
of  the  pericardium,  Burns  found  some  of  the  fleshy  columns  trans- 
formed into  bone.* 

I  am  persuaded  that  a  bony  or  cartilaginous  induration,  as  ex- 
tensive as  that  in  the  three  cases  above  mentioned,  might  be 
recognized  by  the  stethoscope  by  means  of  a  considerable  increase 
and  likewise  a  particular  modification  of  the  sound  of  the  heart. 
I  believe  cases  of  this  kind  are  among  those  in  which  the  sound 
of  the  heart  may  be  heard  at  some  distance  from  the  patient. 
We  frequently  find  on  the  interior  surface  of  the  ventricles,  espe- 
cially the  left,  cartilaginous  scales  continuous  with  the  lining 
membrane,  and  apparently  deposited  between  it  and  the  muscular 
substance  of  the  heart.  These  plates  were  exactly  of  the  same 
kind  as  those  described  by  me  in  another  place,f  and  are  gene- 
rally of  small  extent.  We  ought  to  consider  as  a  variety  of  these 
incrustations,  that  evident  thickening  and  milk-white  color  of  the 
inner  membrane  of  the  left  ventricle,  which  are  frequently  met 
with,  over  a  great  extent,  in  the  case  of  hypertrophy.  I  have 
never  seen  this  after  it  had  reached  the  point  of  ossification  :  but 

*  This  is  not  only  an  imperfect  but  an  incorrect  account  of  the  case  of  Marga- 
ret Henderson  described  by  Burns,  (p.  12!),)  and  which  is  one  of  the  most  extra- 
ordinary on  record.  In  this,  '■'  the  whole  extent  of  the  pericardium  covering 
the  ventricles,  and  the  ventricles  themselves,  except  about  a  cubic  inch  at  the 
apex  of  the  heart,  were  ossified,  and  firm  as  the  skull."  Many  cases  of  partial 
ossification  are  on  record. —  Transl. 

\  Diet,  de  Se.  Med.  Art.  Cart   Accident. 


686  ACCIDENTAL    PRODUCTIONS. 

an  example  of  this  kind  is  described  in  Kreysig's  work,  vol.  iii. 
p.  43.  The  ossification  of  the  auricle,  some  examples  of  which 
we  find  in  the  works  of  Burns,  Kreysig,  and  Bertin,  ought  also, 
in  my  opinion,  to  be  considered  as  the  result  of  these  incrustations 
— at  least  in  the  majority  of  cases.  T  have  met  with  several  eases 
of  this,  over  a  small  extent ;  but  have  never  seen  ossification  of 
the  muscular  substance  of  the  auricles. 


CHAPTER  XVII. 

OF    OTHER    ACCIDENTAL    PRODUCTIONS    FOUND    IN    THE    HEART. 

Of  all  the  organs  of  the  body  the  heart  is  perhaps  the  least  liable 
to  these  productions,  if  we  except  ossifications.  Three  or  four 
times  only  have  I  met  with  tubercles  in  the  muscular  substance 
of  the  heart.  In  the  Sepulchretum  we  meet  with  only  a  small 
number  of  instances  of  tumors  in  this  organ,  which  seem  to  be- 
long to  the  class  of  cancers  or  of  tubercles.*  Columbus  (De  re 
Anat.  1.  xv.),  in  examining  the  dead  body  of  Cardinal  Gambara, 
met  with  two  hard  tumors  of  the  size  of  an  egg  in  the  substance 
of  the  left  ventricle.  Marianus,  in  the  case  of  a  young  man,  com- 
municated by  him  to  Morgagni,  found  numerous  small  tubercles 
implanted  on  the  outer  surface  of  the  right  auricle  ;  (Epist.  lxxviii. 
13  ;)  and  similar  tubercles,  but  much  larger,  were  found  in  the 
mediastinum,  at  the  roots  of  the  lungs,  in  the  lymphatic  glands 
and  cellular  substance  of  the  abdominal  and  thoracic  parietes. 
M.  Recamier  informs  me  that  he  found  the  heart  partly  converted 
into  a  scirrhous  substance,  like  lard,  in  a  case  in  which  there  were, 
moreover,  cancerous  tumors  in  the  lungs.  Within  these  last 
four  years,  I  have  met  with  two  cases  of  the  encephaloid  cancer 
of  the  heart.  In  one  of  these,  the  cancerous  matter  formed  small 
masses,  of  the  size  of  filberts,  or  less,  in  the  muscular  substance 
of  the  ventricles  ;  in  the  other  it  was  deposited  in  layers  of  one 
to  four  lines  thick,  along  the  coronary  vessels,  between  the  peri- 
cardium and  heart.  MM.  Andral  and  Bayle  have  lately  pub- 
lished three  similar  observations  in  the  Revue  M*d.  for  May, 
1824,  and  some  others  have  been  published  more  recently  still. 
From  these  facts  it  may  be  concluded,  that  cancerous  productions 
may  be  developed  in  the  heart,  as  in  other  organs,  under  Jwo 
principal  forms, — that  of  isolated  tumors,  and  that  of  inter- 
stitial deposition,  which  last  constitutes  what  is  commonly  termed 

*  Lib.  ii.  sect.  vii.  obs.  cxii.  •.  sect.  i.  obs.  ii.  :  lib.  iii.  sect.  xxi.  obs.  xxxiii. 


ACCIDENTAL    PRODUCTIONS.  687 

transformation  of  the  organ  into  a  cancerous  substance.  This 
affection  rarely  exists  without  there  being  similar  productions  in 
other  organs,  particularly  the  lungs. 

Serous  cysts  occur  very  seldom  in  the  heart.  '  When  met  with, 
they  are  most  commonly  found  between  the  muscular  substance 
and  the  investing  serous  tunic.  Examples  of  this  kind  are  re- 
lated by  Ballonius,  Houlier,  Cordoeus,  Rolfinckius,*  Thebesius,f 
Fan  ton, J  Valsalva  and  Morgagni.^  Dupuytren  met  with  serous 
cysts  in  the  walls  of  the  ^  right  auricle,  and  projecting  into  its 
cavity  so  as  to  augment  it  to  the  size  of  the  whole  remaining  por- 
tion of  the  heart.  ||  Morgagni  relates  a  case  from  which  it  ap- 
pears that  vesicular  worms  may  be  developed  in  the  heart.  In 
the  body  of  an  old  man,  who  had  died  of  an  acute  disease,  and 
who  had  never  exhibited  symptoms  of  cardiac  disorder,  he  found 
a  cyst  of  the  size  of  a  small  cherry,  half-buried  in  the  walls  of 
the  left  ventricle,  and  when  cut  into,  discharged  "a  small  mem- 
brane, containing  whitish  mucus,  amid  which  one  particle  was 
observed  as  hard  as  tendon."  (Epist.  xxi.  4.)  It  is  impossible 
to  mistake  in  this  description,  the  characters  of  the  genus  custi- 
cercus.  The  small  membrane  full  of  mucus  was  the  caudal  vesi- 
cle, and  the  hard  particle,  was  the  body  doubled  upon  itself. 
From  the  size  we  may  presume  that  it  was  the  cysticercus  finnus 
of  Rudolphi ;  a  presumption  the  more  probable  that  it  is  almost 
the  only  species  that  has  hitherto  been  found  in  the  human 
body.H 
* 

*  Stpulchret.  lib.iii.  sect.  36;  Ibid.  De  Morb.  Intern,  lib.  ii.  cap.  xxix ;  Ibid, 
sect.  xxi.  obs.  xxi. ;  Ibid.  sect.  viii.  obs.  vi. 

t  Ephera.  Nat.  Cur.  cent.  iv.  obs.  cxv.  X  Obs.  Anat.  Med.  xi.  and  xv. 

§  De  Sed.  et  Caus.  Epist.  iii.  26;  Epist.  xxv.  15. 

||  Journ.  de  Med.  t.  v.  p.  139. 

If  Respecting  the  various  morbid  productions  and  degenerations  mentioned  in 
the  present  chapter,  much  more  ample  information  is  to  be  found  scattered 
through  the  writings  of  the  older  and  modern  pathologists,  in  the  systematic 
collections  of  cases  of  morbid  anatomy,  and  in  the  periodical  journals  and 
transactions  of  societies.  For  the  fullest  and  most  accurate  collection  of  refer- 
ences to  the  individual  cases,  I  refer  the  reader  to  the  elaborate  and  very  valua- 
ble Compendium  of  Pathological  Anatomy,  by  professor  Otto,  for  an  excellent 
translation  of  which  the  profession  in  this  country  are  much  indebted  to  Mr. 
South.  In  this  work,  in  the  annotations  to  §  183,  p.  288,  are  pointed  out  the 
sources  whence  ample  information  may  be  procured  on  all  the  subjects  referred 
to  by  our  author,  viz.  Indurated  Tumors,  Steatomes,  Hydatids,  Serous  Cysts, 
Calcareous  Tumors,  Tubercles,  Encephaloid  Cancers  and  Carcinoma. —  Transl. 


688  OSSIFICATION    OF    THE    VALVES. 


CHAPTER  XVIII. 

OF     CARTILAGINOUS    AND    BONY    INDURATION    OF     THE    VALVES    AND 
LINING    MEMBRANE    OF    THE    HEART. 

Sect.  I. — Anatomical  Characters  of  Induration  of  the  Valves. 

The  mitral  and  aortal  valves  are  subject  to  the  growth  of  carti- 
laginous or  bony  productions,  which  increase  their  thickness, 
alter  their  shape,  and  obstruct,  sometimes  almost  totally,  the  ori- 
fices in  which  they  are  placed.  The  tricuspid  and  sigmoid 
valves  of  the  pulmonary  artery  are  much  less  subject  to  these 
alterations,  although  they  are  not  quite  exempt  from  them,  as 
Bichat  thought.  Morgagni  found  (Epist.  37)  in  the  case  of  an 
old  woman,  both  these  partially  indurated.  He  likewise  found, 
in  a  young  woman,  the  sigmoid  valves  of  the  pulmonary  artery 
agglutinated  by  means  of  a  cartilaginous  induration,  partly  ossi- 
fied, so  as  considerably  to  diminish  the  diameter  of  the  artery. 
In  this  patient  the  foramen  ovale  was  likewise  open,  and  the 
symptoms  of  the  blue  disease  were  present.  Vieusens,  Hunauld, 
Bertin  senior,  and  Horn,  have  met  with  instances  of  bony  or  car- 
tilaginous indurations  on  the  valves  of  the  cavities  of  the  right 
side.  (See  Kreysig  and  Bertin.)  But  of  all  the  cases  of  this  kind, 
none  is  more  extraordinary  than  one  observed  by  Criiwell.*  In 
this,  the  tricuspid  and  mitral  valves  were  cartilaginous  in  several 
places  ;  small  bony  concretions  existed  in  the  vena  cava ;  laminae 
of  bone  extended  from  the  base  of  the  right  auricle  under  the  in- 
ternal membrane  of  the  ventricle,  some  of  the  columnar  carnoo  of 
which  were  ossified  :  and,  finally,  lamminae  still  thinner  and  nar- 
rower, bony  or  cartilaginous,  penetrated  the  muscular  substance 
of  the  two  ventricles.  A  small  hollow  globular  body,  perforated 
by  two  openings  of  a  partly  cartilaginous  and  partly  bony  tex- 
ture, was  fixed  between  the  valves  of  the  pulmonary  artery.  This 
body  seemed  to  have  been  recently  detached  from  the  interven- 
tricular septum,  and  still  retained  at  one  end  some  marks  of  its 
adhesion.  The  pericardium  was  attached  to  the  heart  and  con- 
tained some  ossified  points.  Corvisart  twice  observed  the  carti- 
laginous induration  of  the  base  of  the  tricuspid  valve,  and  ano- 
ther is  recorded  in  his  journal,  which  occurred  in  the  person  of 
an  English  general.!  Burns  likewise  gives  a  case  of  partial  ossi- 
fication of   the  tricuspid  valves,  (Op.  Cit.  p.  31,)    and  Bertin 

De  Cord,  et  Vasor.  osteogenesi  in  quudragenario  obscrv   Halm,  17G5. 
t  Journ.  do  Med.  t.  xix.  p.  468. 


OSSIFICATION    OF    THE    VALVES.  689 

informs  us,  that  in  the  course  of  twenty  years,  he  has  four  times 
met  with  a  cartilaginous  induration  of  the  same  parts.  He  has 
published  one  of  these  cases  (Obs.  LIV.)  "  in  which  the  laminae  ot 
tricuspid  valve,  hard,  thickened,  and  united  together  by  their 
edges,  formed  a  sort  of  cartilaginous  septum,  perforated  in  its 
center  by  an  opening,  scarcely  capable  of  admitting  the  point  of 
the  little  finger."  I  have  myself  sometimes  met  with  slight  car- 
tilaginous incrustations  both  at  the  base  and  point  of  the  tricus- 
pid valves,  and  also  of  the  sigmoid  of  the  pulmonary  artery. 
Once  only  have  I  seen  these  advanced  to  the  stage  of  ossification  ; 
and  it  ought  to  be  observed  that  in  almost  all  the  cases  alluded 
to,  the  induration  of  the  valves  on  the  right  side  was  only  carti- 
laginous. It  is  especially  in  cases  of  preternatural  communica- 
tion between  the  cavities  of  the  heart,  that  the  valves  of  the  right 
side  have  been  found  affected.  Bertin  relates  a  case  of  this  kind 
communicated  to  him  by  M.  Louis  (Obs.  LVII.)  in  which  the 
tricuspid  valve  was  partly  ossified,  and  the  sigmoid  valves  of  the 
pulmonary  artery  formed  a  sort  of  fibrous  ring  hardly  two  lines 
and  a  half  in  width.  In  this  case  there  was  a  small  opening,  two 
lines  wide,  between  the  right  ventricle  and  the  origin  of  the  aorta. 
In  another  case  observed  by  M.  Bertin  himself  (Obs.  LVI.)  the 
foramen  ovale  was  unclosed,  and  the  mouth  of  the  pulmonary 
artery  was  "  closed  by  a  horizontal  septum,  pierced  by  an  open- 
ing two  and  a  half  lines  in  width."  From  these  facts  it  appears 
probable  that  the  action  of  the  arterial  blood  has  a  great  influence 
over  the  production  of  bone  in  the  heart,  an  opinion  rendered 
still  more  probable,  by  the  consideration  of  the  great  frequency 
of  these  in  the  valves  of  the  left  side  of  the  heart.  I  have  some- 
times noticed  small  cartilaginous  incrustations  both  on  the  base 
and  at  the  extremities  of  these  valves.* 

The  cartilaginous  induration  of  the  mitral  valve  is  sometimes 
confined  to  the  fibrous  bands  found  in  its  base.  In  this  case  it 
has  the  appearance  of  a  very  smooth,  though  unequal  ring,  les- 
sening the  orifice  in  which  it  is  situated.  This  sometimes  has  the 
consistence  of  perfect  cartilage,  sometimes  only  that  of  imperfect 
cartilage.  Similar  incrustations  sometimes  are  met  with  in  other 
parts  of  these  valves  ;  but  those  at  the  basis  or  points  are  com- 
monly thickest.  The  bony  indurations  present  the  same  charac- 
ters as  to  situation,  and  are  still  more  unequal  as  to  thickness. 
Though  formed  in  the  interior  of  the  valve,  they  often  project 
from  it  quite  uncovered  ;  and  are  so  rough  as  to  have  led  some 
authors  to  consider  them  as  carious.  These  ossificates  are  never 
perfect  bone  ;  they  are  whiter  and  more  opaque,  more  fragile,  and 

*  Dr.  Latham  has  found  the  right  valves  affected  in  one-third  of  the  cases  in 
which  the  left  were  ;  Dr.  Hope  has  found  the  proportion  smaller,  one  in  lour  or 
live. —  Transl. 

87 


690  OSSIFICATION    OF    THE    VALVES. 

evidently  contain  a  greater  proportion  of  phosphate  of  lime.  On 
this  account  they  have  been  frequently  named  stones  or  calculi. 
In  fact,  they  frequently  bear  a  striking  resemblance  to  small 
pieces  of  stones,  of  very  irregular  surface,  recently  broken  ;  more 
especially  when  they  are  very  rough,  and  have  pierced  and  des- 
troyed, over  a  great  extent,  the  membrane  which  originally  in- 
vested them.  When  they  are  situated  in  the  floating  extremities 
of  the  valve,  these  are  occasionally  united  together,  so  as  to  reduce 
the  orifice  to  a  mere  slit,  which  will,  sometimes,- scarcely  admit 
the  blade  of  a  knife  or  a  goose-quill.  M.  Corvisart  found  the 
orifice  between  the  auricle  and  ventricle  reduced  to  a  channel 
three  lines  wide,  and  bent  like  the  canalis  caroticus,  from  the 
thickening  of  the  ossified  mitral  valve.  Sometimes,  though  rarely, 
the  tendinous  cords  of  the  mitral  valve  are  affected  in  the  same 
manner  ;  and  M.  Corvisart  in  one  case  found  the  whole  of  one  of 
its  pillars  ossified.     (Op.  Cit.  p.  212.*) 

The  ossification  of  the  sigmoid  valves  of  the  aorta  may  com- 
mence, like  that  of  the  mitral,  in  their  base  or  their  loose  edges  ; 
at  least,  the  greater  frequency  of  occurrence,  and  the  greater 
thickness  of  these  two  parts,  and  the  comparative  rarity  of  ossi- 
fication in  the  intermediate  portions,  seem  to  indicate  the  ossifi- 
cation as  beginning  in  these  points.  When  in  the  loose  extremity, 
the  ossification  seems  most  frequently  to  originate  in  the  small 
tubercles  known  by  the  name  of  the  corpora  sesamoidea. 

When  the  ossification  is  confined  to  the  floating  edge  of  the 
valves,  or  when  the  base,  though  ossified,  is  little  thickened,  the 
valve  may  still  perform  its  functions,  provided  the  middle  portion 
of  it  be  still  sound.  But  when  the  ossification  is  extensive,  the 
valves  grow  together,  and  get  incurvated,  either  towards  their 
concave  or  convex  side,  so  as  to  acquire  the  appearance  of  certain 
shells.  In  this  state  they  are  immovable,  being  either  fixed  on 
the  side  of  the  aorta,  or  in  the  orifice  of  the  ventricle.  Very 
frequently,  of  the  three  valves  one  is  bent  in  a  direction  opposite 
that  of  the  two  others.  In  one  case,  M.  Corvisart  found  all  the 
three  valves  ossified  in  their  closed  position  so  as  to  leave  merely 
an  extremely  small  slit  for  the  passage  of  the  blood.  The  evil  of 
this  was  partly  obviated  by  one  of  the  valves,  although  ossified 
and  very  thick,  still  retaining,  at  its  base  sufficient  mobility  to 
allow  an  increase  of  one  or  two  lines  to  the  orifice  during  the 
action  of  the  heart.    (Op.  Cit.  p.  220.)    In  one  case  (Obs.  LIII.) 

In  one  of  my  cases  of  diseased  heart,  (Original  Cases,  p.  133,)  three  of  the 
pillars  of  the  mitral  valve  were  completely  ossified  through  their  whole  extent, 
with  the  exception  of  a  minute  portion  at  each  extremity,  which  was  semi-car- 
tilaginous or  fibrous,  and  flexible ;  an  arrangement  which  seemed  absolutely 
necessary  to  admit  the  natural  contraction  of  the  ventricle—  Transl. 


OSSIFICATION    OF    THE    VALVES. 


691 


M.  Bertin  found  the  three  sigmoid  valves  ossified,  and  one  of 
them  enlarged  to  the  size  of  a  pigeon's  egg.* 

Sect.  II. — Signs  of  Induration  of  the  Valves. 

The  symptoms  of  ossification  of  the  mitral  valve  are  little  dif- 
ferent from  those  attending  the  same  affection  of  the  sigmoid.f 

*  One  of  the  most  remarkable  cases  of  valvular  disease  of  the  heart  that  I  have 
met  with,  is  that  of  Mary  Horn,  recorded  in  my  Original  Cases,  p.  178;  and  the 
diagnosis  of  which  (as  far  as  the  valves  were  concerned)  was  very  accurately 
established  by  means  of  the  stethoscope.  This  girl  died  shortly  after  the  last 
report  given  in  the  published  case.  The  organic  lesions  found  on  dissection 
were  the  following  : — the  right  auriculo-ventricular  opening  was  converted  into 
a  circular  foramen  (capable  of  admitting  the  thumb)  with  smooth  rounded  carti- 
laginous edges ;  the  left  auriculo-ventricular  opening  had  undergone  precisely 
the  same  change,  only  th$  orifice  on  this  side  admitted  the  point  of  the  finger 
with  difficulty  the  sigmoid  valves  of  the  aorta  were  cartilaginous  and  united 
together,  so  as  to  leave  a  mere  slit  just  capable  of  admitting  a  large  goose-quill. 
Both  auricles  were  dilated ;  the  right  in  an  extreme  degree  ;  the  left  ventricle 
was  enormously  hypertrophied,  with  diminution  of  its  cavity ;  the  right  very 
slightly  hypertrophied  but  dilated.  The  whole  heart  was  of  an  immense  size. — 
Transl. 

t  Our  author  here,  as  elsewhere,  in  his  zeal  for  physical  diagnosis,  overlooks 
the  ordinary  or  general  symptoms  of  the  disease.  In  the  present  case  of  disease  of 
the  valves,  the  symptoms  are  certainly,  at  best,  only  equivocal  indications  of  the 
pathological  state  of  the  heart;  still  they  are  far  from  being  valueless  as  signs, 
whether  taken  singly  or  in  conjunction  with  those  afforded  by  the  stethoscope. 
In  briefly  noticing  these  in  this  place,  I  am  almost  compelled  to  avail  myself  of 
the  observations  of  Dr.  Hope,  as  they  are  so  strictly  in  accordance  with  my  own, 
that  if  I  did  not  formally  quote  his  work,  I  should  have  the  appearance  of  bor- 
rowing, without  acknowledgment.  (See  his  Treatise  on  diseases  of  the  Heart, 
and  the  article  on  Diseases  of  the  Valves  of  the  Heart,  tn  the  Cyclopaedia  of 
Pract.  Med.) 

"  Whether  the  disease  of  the  valves  be  cartilaginous,  osseous,  or  consist  of 
vegetations,  the  general  symptoms  are  the  same,  if  the  degree  of  contraction  be 
equal.  These  are — cough,  copious  watery  expectoration,  dyspnoea,  ortho- 
pncea,  frightful  dreams  and  starting  from  sleep,  turgescence  of  the  jugular 
veins,  lividity  of  the  face,  anasarca,  injection  of  almost  all  the  mucous  mem- 
branes, passive  haemorrhages,  especially  of  the  mucous  membranes,  engorgement 
of  the  liver,  spleen,  <fec.  and  congestion  of  the  brain,  with  symptoms  of  oppres- 
sion sometimes  amounting  to  apoplexy. 

"  The  peculiar  and  distinctive  symptoms  of  valvular  disease  are  the  follow- 
ing : — When  the  disease  is  combined  with  hypertrophy  or  dilatation,  as  is  com- 
monly the  case,  the  symptoms  are  more  severe  than  those  of  hypertrophy  or  of 
dilatation  alone,  the  paroxysms  of  palpitation  and  dyspnoea  in  particular,  be- 
ing more  violent,  more  obstinate,  and  more  easily  excited.  The  action  of  the 
heart  is  irregular.  This,  it  is  true,  may  sometimes  be  the  case  in  hypertrophy 
and  in  dilatation,  but  here  it  is  an  accidental,  not  an  essential  character.  The 
pulse  may  in  valvular  disease  be  small,  weak,  intermittent,  irregular,  and  un- 
equal ;  and  it  may  even  be  small  and  weak  while  the  heart  is  giving  a  violent 
impulse — a  contrast  which  aftbrd3  one  of  the  strongest  presumptions  of  valvular 
disease.  The  characters  of  the  pulse  just  described,  are  most  marked  in  con- 
traction of  the  mitral  valve ;  and,  if  its  contraction  be  great,  they  are  all  inva- 
riably present ;  for  as,  in  this  case,  the  left  ventricle  is  not  freely  supplied  with 
blood,  it  is  not  stimulated  to  contract  at  the  natural  intervals  and  with  suitable 
energy.  A  slight  contraction  of  the  mitral,  (when,  for  instance,  the  diameter 
of  the  aperture  is  not  diminished  more  than  a  quarter  of  an  inch,)  does  not  nec- 
essarily produce  an  unsteady  pulse,  as  it  still  allows  of  an  adequate  supply  of 
blood  to  the  ventricle.  When,  however,  the  circulation  is  hurried,  the  pulse 
generally  becomes   unsteady.     Contraction  of  the  aortic  valves  must  be  very 


692  OSSIFICATION    OF    THE    VALVES. 

According  to  M.  Corvisart  the  principal  sign  of  the  former  lesion 
is  "  a  peculiar  rustling  sensation  (bruissement)  perceived  on  the 
application  of  the  hand  to  the  region  of  the  heart."  This  pe- 
culiar sensation  is  nothing  else  than  the  pur  ring-thrill  already 
described.  It  is  assuredly  very  frequently  observed  in  the  case 
of  ossification  of  the  mitral  or  sigmoid  valves  when  this  exists  in 
a  high  degree ;  but,  as  I  formerly  stated,  it  may  exist  when  these 
valves  are  perfectly  sound,  and  it  is  almost  always  absent  when 
the  induration  is  not  so  extensive  as  materially  to  obstruct  the 
orifices.  The  bellows-sound  is  a  much  more  constant  sign :  it 
accompanies  the  contraction  of  the  left  auricle  when  the  mitral 
valve  is  affected,  and  that  of  the  ventricle,  when  the  induration 
is  in  the  sigmoid.  But  even  this  is  wanting  when  the  alteration 
is  not  extensive,  and  as  it  is,  moreover,  very  common  when  the 
heart  is  perfectly  sound,  we  must  lay  no  stress  on  it  as  a  sign, 
unless  it  be  combined  with  other  circumstances  calculated  to 
confirm  the  diagnosis.  Accordingly,  when  the  sound  of  the  bel- 
lows, rasp,  or  file,  persists  in  the  left  auricle,  either  continuously 
or  interruptedly,  for  several  months  ; — when  it  is  found  only 
there,  and  exists  even  in  the  greatest  quietude, — when  it  is 
scarcely  lessened  by  venesection,  or,  when  lessened,  if  it  still 
leaves  behind  it  a  degree  of  roughness  in  the  sound  of  the  auri- 
cle,— or,  yet  more,  when  the  purring-thrill  co-exists  with  this  ; — 
we  may  be  assured  that  the  left  auriculo-ventricular  orifice  is 
contracted.*  If  the  same  phenomena  occur,  under  similar  cir- 
cumstances, in  the  left  ventricle,  we  may  be  equally  certain  that 
the  aortal  orifice  is  contracted. 

great  to  render  the  pulse  small,  weak,  intermittent,  and  irregular.  I  have  never 
seen  it  possess  these  characters  in  any  marked  degree  unless  the  valves  were 
either  soldered  together  hy  cartilaginous  degeneration,  or  more  or  less  fixed  by 
ossification  in  the  closed  position,  so  that  the  aperture  was  only  a  limited  chink. 
An  induration  the  size  of  an  ordinary  pea,  has  little  effect  on  the  fullness,  firm- 
ness, and  regularity  of  the  pulse,  and  slighter  degrees  of  contraction  appear  to 
have  no  effect  on  it  whatever.  The  pulse  is  less  irregular  when  the  valvular 
contraction  is  on  the  right  side,  than  when  it  is  on  the  left :  it  is  not  so  small 
and  weak  from  a  contraction  on  the  right  side  as  on  the  left,  and  contraction  of 
the  tricuspid  valve  causes  more  irregularity  than  contraction  of  the  valves  of 
the  pulmonary  artery.  Pain  in  the  region  of  the  heart  is  another  symptom  of 
disease  of  the  valves.  It  is  true  that  palpitation  may  occasion  pain,  though  there 
be  no  disease  of  the  valves,  and  I  have  frequently  met  with  it  from  this  cause  in  hy- 
pertrophy and  dilatation.  It  is  likewise  true  that  palpitation  may  occasion  pain 
though  there  be  no  disease  of  the  heart  whatever ;  I  have  often  found  it  in  hys- 
terical females,  and  in  nervous  men.  But  it  is  when  the  valves,  the  coronary 
arteries,  or  the  commencement  of  the  aorta,  are  indurated  and  inelastic,  that 
pain  occurs  most  frequently  and  with  the  greatest  severity.  Sometimes  it  is  lit- 
tle more  than  an  indescribable  sense  of  obstruction  or  oppression  in  the  proecor- 
dial  region  ;  but,  in  other  cases,  it  is  an  intense  lancinating  or  tearing  pain,  felt 
across  the  proecordia  or  scrobiculous  cordis,  (where  it  might  be  mistaken  for  in- 
flammation of  the  stomach,)  and  occasionally  extending,  with  a  sense  of  numb- 
ness, down  the  left  arm  to  the  elbow,  and  sometimes  to  the  fingers.  Pain  of 
this  description  has  acquired  the  name  of  angina  pectoris." — Transl. 

*  This  contraction  is  more  frequently  owing  to  ossification  of  the  mitral  valve 
than  to  any  other  cause. — Author. 


OSSIFICATION    OF    THE    VALVES. 


693 


Three  or  four  times,  during  the  last  four  years,  I  have  disco- 
vered this  lesion,  by  means  of  these  signs.  Three  similar  exam- 
ples, equally  verified  by  dissection,  are  recorded  in  M.  Bertin's 
Work  ;  (Obs.  49,  50,  51.)  and  a  fourth  is  given  in  the  collection 
of  cases  published  by  Dr.  Forbes.  (Case  VII.)  But  if  these 
phenomena  exist  only  for  a  time,  although  as  much  as  two  or 
three  months, — if  they  accompany  the  increase  of  any  other  ner- 
vous or  organic  disease  of  the  heart,  we  must  not  depend  upon 
them  as  indications  of  the  lesions  now  in  question  ;  since  all  the 
facts  formerly  recounted  prove  that  these  sounds  are  not  pro- 
duced (as  might  be  imagined  at  first)  by  the  passage  of  the  blood 
over  a  rough  or  rugged  surface,  but  to  the  spasmodic  energy  req- 
uisite in  the  muscular  contraction  to  overcome  the  obstacles  op- 
posed to  it.  It  follows,  therefore,  that  any  other  cause  besides 
diminution  of  the  size  of  the  orifices,  which  occasions  contraction 
of  the  heart,  is  equally  capable  of  giving  occasion  to  the  bellows- 
sound  and  purring  thrill :  and  it  is  fair  to  admit  that,  in  the  first 
edition  of  this  work,  I  laid  too  much  stress  on  these  two  pheno- 
mena as  signs  of  valvular  disease.* 

*  It  is  true  that  we  must  not  attach  too  much  importance  to  the  bellows-sound 
as  a  sign  of  disease  ;  but  I  am  of  opinion  (as  I  formerly  stated,  p.  596.)  that  we 
ought  to  have  more  confidence  in  the  sound  of  the  rasp,  accompanied  by  the 
purring-thrill.  I  am  surprised  that  Laennec  did  not  make  a  distinction,  in  this 
respecr,  between  the  two.  The  bellows-sound  very  rarely,  and  only  at  inter- 
vals, assumes  the  sound  of  the  rasp.  When  the  latter  exists,  we  may  be  sure 
that  there  is  an  obstruction  to  the  course  of  the  blood  from  disease  of  the  valves. 
It  is  proper  to  remark,  however,  that  the  converse  is  not  always  true  :  there 
may  be  obstruction  without  any  sound  of  the  rasp.  In  several  instances  I  have 
found  the  aortal  valves  ossified  in  subjects  in  whom  the  auscultation  of  the  heart 
produced  no  anomaly,  except  perhaps  increased  impulse.  I  do  not,  however, 
recollect  having  found  the  mitral  valve  ossified,  without  a  change  in  the  charac- 
ter of  the  second  sound. — (M.  L.) 

The  following  observations  by  Dr.  Hope,  on  the  important  points  noticed  in 
the  above  note,  merit  the  greatest  attention  : — 

"  Bellows-murmur  sometimes  exists  in  the  heart  though  there  be  no  disease  of 
the  valves;  namely,  in  nervous  persons,  in  cases  of  re-action  from  excessive  loss 
of  blood,  of  pericarditis  and  adhesion  of  the  pericardium,  and  of  hypertrophy 
with  dilatation.  Murmur  from  these  causes  may  easily  be  distinguished  from 
that  of  valvular  disease,  by  the  following  criteria :— When,  from  nervous  excite- 
ment, very  common  in  hysterical  females,  it  may  be  known  by  its  being  inter- 
mittent, ceasing  when  the  nervous  exacerbation  subsides  and  the  action  of  the 
heart  becomes  calm.  When  from  re-action,  it  subsides  with  the  cessation  of 
that  phenomenon.  When  from  pericarditis  or  adhesion  of  the  pericardium,  it 
may  be  known  by  the  presence  of  signs  of  those  affections.  When  from  hyper- 
trophy with  dilatation, it  may  be  known  by  its  diminishing  or  ceasing  when  the 
action  of  the  heart  is  calmed,  as  by  repose,  venesection,  abstinence,  &c.  <fcc. 
Contrasted  with  the  above,  the  distinctive  characters  of  valvular  murmur  are, 
that  it  is  not  universal  over  the  heart,  but  confined  in  a  great  measure  to  the  part 
corresponding  to  the  valve  affected  ;  that  it  persists  without  intermission  for  an 
indefinite  length  of  time,  even  though  the  heart  be  kept  in  a  state  of  perfect 
calm  ;  and  that  it  is  often  of  the  filing,  rasping,  or  sawing  kind  ;  whereas  mur- 
murs from  other  causes  have  almost  always  the  softness  of  the  bellows-sound. 
This  murmur  has  a  soft  character,  like  that  of  bellows,  when  the  contraction  has 
a  smooth  surface  which  does  not  greatly  break  the  stream  of  blood,  as  when  the 
morbid  deposition   consists  of  cartilage,  fibro-cartilage.  or  vegetations.     But  the- 


«)«)!  OSSIFICATION    OF    THE    VALVES. 

A  slight  degree  of  cartilaginous  or  bony  induration  of  the 
valves  may  exist  for  a  long  time  without  any  visible  alteration  of 

murmur  is  rougher  or  more  grating,  like  that  of  a.  file  or  rasp,  when  the  deposi- 
tion has  a  rugged,  hard  surface,  as  when  it  is  osseous.  Murmurs  are  more  hol- 
low when  they  are  deep  seated,  as  for  instance,  in  the  auriculo-ventricular  ori- 
fices ;  and  more  hissing  or  whizzing  when  they  are  superficial,  as  in  the  aortic 
orifice,  more  especially  in  the  pulmonary  orifice,  and  the  ascending  aorta.  The 
hollowness  of  the  sound  is  referable  to  its  remoteness  and  its  reverberation  through 
the  chest.  The  sawing  murmur  is  almost  identical  with  the  filing  or  rasping; 
it  is  only  less  grating  and  on  a  higher  key.  The  musical  bellows-murmur  is  a 
perfect  note  like  whistling  or  cooing.  In  the  case  of  a  patient  who  applied  to 
me  for  '  a  noise  in  the  chest,'  I  heard  it  at  the  distance  of  two  feet.  In  a  case 
precisely  similar,  which  occurred  to  Dr.  Elliotson,  there  was  a  very  large  and 
long  vegetation  in  the  mitral  valve.  As  purring  tremor  has  the  same  origin  as 
bellows  and  other  murmurs,  it  often  accompanies  them  ;  though,  as  it  requires  a 
greater  degree  of  disease  for  its  production,  this  is  not  always  the  case.  It  may 
be  occasioned  by  obstruction,  not  only  of  the  semi-lunar,  but  also  of  the  mitral 
and  tricuspid  valves,  and  in  the  latter  cases  it  may  accompany  either  the  first  or 
the  second  sound.  When  accompanying  the  first.it  proceeds  from  regurgitation 
through  the  valve;  and  when  accompanying  the  second,  it  results  from  the  im- 
peded passage  of  the  blood  from  the  auricle  into  the  ventricle  during  the  ven- 
tricular diastole.  It  rarely  accompanies  the  second  sound;  because,  as  we  con- 
ceive, the  diastole  current  is  seldom  strong  enough  to  produce  it.  When  from 
disease  of  the  mitral  valve,  it  is  not  perceptible  in  the  pulse." — (Cyc.  of  Pract. 
Med.  vol.  iv.) 

For  by  far  the  completest  and  most  accurate  account  of  the  physical  diagnos- 
tics of  diseases  of  the  valves,  I  refer  the  reader  to  Dr.  Hope's  Treatise  on  Dis- 
eases of  the  Heart,  and  to  his  very  valuable  article  just  quoted  (Valvesof  the 
heart,  diseases  of,)  in  the  fourth  vol.  of  the  Cyclopaedia  of  Practical  Medicine. 
It  is  very  satisfactory  to  learn  from  so  experienced  an  auscultator  as  Dr.  Hope, 
not  only  that  Laennec's  mistake  (for  such  I  think  we  must  now  admit  it  to  be) 
respecting  the  cause  of  the  second  sound,  scarcely  vitiates  the  conclusions  de- 
duced by  him  as  to  the  particular  parts  affected,  but  that  the  signs  discovered  by 
him  are  of  more  value  than  he  himself  believed.  "  The  accession  of  ausculta- 
tion (says  Dr.  Hope)  to  the  other  means  of  diagnosis,  has  rendered  it  possible  to 
distinguish  valvular  disease  with  almost  complete  certainty  :  a  certainty,  it  may 
be  remarked,  much  greater  than  was  supposed  by  the  illustrious  author  of  aus- 
cultation himself;  for  he  did  not  give  their  full  value  to  preternatural  murmurs  as 
signs  of  disease  of  the  valves,  in  consequence  of  supposing  that  similar  murmurs 
were  produced    by  a  spasmodic    contraction  of  the  muscular   fibre  of  the    heart, 

and  even  of  the  arteries Laennec  labored  under  another  disadvantage  :  he 

attributed  the  second  sound  of  the  heart  to  the  auricular  contraction;  whereas, 
according  to  the  experiments  of  the  writer,  it  is  referable  to  the  ventricular  di- 
astole. The  substitution  of  this  view  of  the  heart's  action  for  that  of  Laennec, 
fortunately  does  not  falsify  any  of  his  physical  signs,  except  one,  viz.  that  '  loud- 
ness of  the  second  sound  indicates  dilatation  of  the  auricles:'  it  does  not,  to 
adduce  a  single  instance,  invalidate  the  fact  that  murmur  of  the  second  sound 
indicates  disease  of  the  auricula-ventricular  valve  ;  but  it  affords  a  rational  ex- 
planation of  all  the  phenomena  noticed  by  Laennec,  and  renders  various  others 
available  as  signs,  which  to  him  were  inexplicable  and  therefore  useless." — 
(Loc.  Cit.J 

The  following  brief  extracts  from  the  same  work  of  Dr.  Hope,  give  an  accurate 
but  incomplete  view  of  the  diagnostics  of  the  particular  affections  :  for  a  fuller 
account  I  must  refer  to  the  original  article  and  to  his  treatise.  "  Signs  of  disease 
of  the  aortic  valves. — One  of  the  murmurs  above  described  is  heard  during  the 
ventricular  contraction  about  the  middle  of  the  sternum,  and  is  louder  here 
than  elsewhere.  It  is  more  or  less  hissing  or  whizzing,  from  being  superficial, 
and  it  accordingly  conveys  the  idea  of  being  near  to  the  ear.  When  a  murmur 
of  this  kind  is  louder  along  the  tract  of  the  ascending  aorta  than  opposite  to  the 
valves,  and  is,  at  the  same  time,  peculiarly  superficial  and  hissing,  it  proceeds 
from  disease  of  the  aorta  itself.     As  a  murmur  from  this  source  often  extends  to 


OSSIFICATION    OF    THE    VALVES. 


695 


the  health,  or  even  of  the  action  of  the  heart ;  and  even  by  pro- 
per measures  of  precaution  and  by  seasonable  bleedings,  we  may 
frequently  preserve  for  a  long  time  the  life  of  individuals,  who 
present  every  sign  of  considerable  contraction  of  the  orifices. 
The  following  case  is  a  proof  of  this. 

Case  XLV. — A  very  muscular  young  man,  aged  sixteen, 
came  into  the  Necker  Hospital  in  February,  1819,  complaining 
of  oppression  on  the  chest  and  palpitation ;  symptoms  which  had 
seized  him  suddenly,  together  with  haemoptysis  and  epistaxis, 
two  years  before.  These  symptoms  were  relieved  at  the  time, 
by  rest ;  but  returned  as  often  as  he  made  any  considerable  de- 
gree of  exertion.  He  presented  the  following  symptoms  on 
coming  into  the  hospital ;  respiration  and  resonance  good  over 
the  whole  chest ;  the  hand  applied  to  the  region  of  the  heart  feels 
the  pulsations  strongly,  and  accompanied  with  the  purring  vibra- 
tion. This  vibratory  sensation  is  not  continuous,  but  returns  at 
regular  intervals.  The  stethoscope,  applied  between  the  cartila- 
ges of  the  fifth  and  seventh  ribs,  gives  the  following  results : — 
contraction  of  the  auricle  extremely  prolonged,  accompanied  with 

the  situation  of  the  valves,  it  might  easily  lead  to  the  supposition  that  they  also 
were  diseased,  and  it  is  sometimes  very  difficult  to  ascertain  positively  that  they 
are  not.     A  murmur  may  accompany  the  second  sound  when  there  is  regurgita- 
tion through  the  aortic  valves,  and  its  source  may  be  known  by  its  being  louder 
and  more  superficial  opposite  to  those  valves  than    elsewhere.     Signs  of  disease 
of  the  mitral  valve. — When  this  valve  is  contracted,  the    second  sound  loses,  on 
the  left  side,  its  short,  flat,  and  clear  character,  and  becomes  a  more  or  less  pro- 
longed  bellows-murmur.     When  the  valve  is  permanently  patescent,  admitting 
oi  regurgitation,  the   first  sound    likewise   is  attended   with  a  murmur.       These 
murmurs  are  louder  opposite   to  the  mitral  valve,  (viz.  at   the  left  margin  of  the 
sternum,  between  tlie  third  and  fourth  ribs,  i.  e.  about  three  or  four  inches  above 
the  point  where  the  apex  of  the  heart  beats,)  than  elsewhere.     They  are  also 
more  hollow  than  murmurs  of  the  aortic  valves.     Signs  of  disease  of  the  aortic 
and  mitral  valve  conjointly. — The  murmurs  above  described   as  characteristic  of 
each,  exist  simultaneously  in  the  situation  of  each.     If  the  murmurs  of  the  first 
sound  be  of  a  different  species  in   the  two  situations — if,  for  instance,  the  mur- 
mur of  the  aortic  valves  be  of  the  bellows  kind,  and  that  of  the  mitral  resemble 
filing  or  rasping,  it    is  still    easier  to  determine  that  both    valves  are  diseased. 
Signs  of  regurgitation  through  the  mitral  valve. — These  signs  are  a  murmur  with 
the  first  sound,  louder  in  the   situation  of  this   valve  than  of  the  aortic;  and  a 
weak  pulse,  even   though  the  impulse  of  the  heart  be  violent.     It  is  generally 
unsteady  also.       Signs  of  disease   of  the  pulmonic  valves. — The  signs    are  the 
same  as  those  of  disease  of  the  aortic  valves,  with  this  difference,  that  the  mur- 
mur seems  close  to  the  ear,  and  is  equally  hissing  as  in  disease  of  the  ascending 
aorta.     Disease  of  the  pulmonic    valves  is  so  rare  that  it  ought  never  to  be  sus- 
pected unless  the  signs  described  are  extremely  well  marked,  or  unless  there  be 
patescence  of  the  foramen  ovale,  or  some   other  preternatural  communication 
between  the  two  sides  of  the    heart — states,  which  experience   has  proved  to  be 
in  general  accompanied  with  contraction  of  the  pulmonic  orifice.     Signs  of  dis- 
ease of  the  tricuspid  valve. — They  are    the  same  as   those  of  disease  of  the  mi- 
tral, except  that  the  murmurs  are  loudest  opposite  to  the  valve  :  viz.  at  the  mid- 
dle part  of  the  sternum,  opposite  to  the  inter-space  between  the  third  and  fourth 
ribs,  and  a  little  to  the  right  of  the  mesial   line.     As  this  valve  is   very  seldom 
affected,  the  practitioner  must  be  very  cautious  in  pronouncing  it  diseased,  espe- 
cially as  the  pulse  does  not  afford  the  same  evidence  as  in  contraction  of  the  mi- 
tral orifice." — (Loc.  Cit.) — Transl. 


696  OSSIFICATION    OF    THE    VALVES. 

a  dull  but  strong  sound  exactly  like  that  produced  by  a  file  on 
wood.  This  sound  is  attended  by  a  vibration  sensible  to  the  ear, 
and  which  is  evidently  the  same  as  that  felt  by  the  hand.  Suc- 
ceeding this,  a  louder  sound  and  a  shock  synchronous  with  the 
pulse  point  out  the  contraction  of  the  ventricle,  which  occupies 
only  one  fourth  the  time,  and  has  something  harsh  in  its  sound. 
Under  the  lower  end  of  the  sternum  the  contractions  of  the  heart 
are  quite  different.  Here  the  impulse  of  the  right  ventricle  is 
very  great,  its  contraction  accompanied  by  a  very  distinct  sound, 
and  being  of  the  ordinary  duration  ;  viz.  twice  as  long  as  that  of 
the  auricle.  The  sound  of  the  auricle  is  somewhat  obtuse,  but 
without  anything  analogous  to  the  vibratory  character  of  the  left. 
The  action  of  the  heart  is  audible  below  both  clavicles,  on  both 
sides,  but  feebly,  especially  on  the  right.  Over  the  whole  ster- 
num, on  the  right  side  and  below  the  left  clavicle,  the  contractions 
of  the  heart  have  the  same  rythm  as  at  the  end  of  the  sternum. 
On  the  left  side,  on  the  contrary,  the  whizzing  sound  of  the  left 
auricle  already  described  is  much  feebler  than  in  the  left  pre- 
cordial region.  From  these  signs  the  following  diagnostic  was 
given — Ossification  of  the  mitral  valve,  slight  hypertrophy  of 
the  left  ventricle ;  perhaps  slight  ossification  of  the  sigmoid 
valves  of  the  aorta ;  great  hypertrophy  of  the  right  ventricle. 
The  pulse,  in  this  case,  was  pretty  strong  and  very  regular,  and 
all  the  functions  natural,  only  the  sleep  was  habitually  disturbed 
by  frightful  dreams,  and  the  lad  could  not  use  any  severe  exer- 
cise, nor  even  walk  rather  fast,  without  being  attacked  by  strong 
palpitations  and  a  feeling  of  suffocation.  Four  venesections, 
after  intervals  of  a  few  days,  gave  much  relief.  After  the  first, 
the  pube  became  weak  ;  and  immediately  after  each  bleeding  the 
purring  vibration  became  imperceptible  to  the  hand,  and  the 
whizzing  of  the  auricle  changed  from  the  sound  of  a  file  to  that 
of  a  bellows,  the  valve  of  which  we  keep  open  by  the  hand ;  the 
shock  of  the  right  ventricle  continued  to  be  very  strong.  This 
patient  left  the  hospital  after  a  month,  being,  in  his  own  opinion, 
pretty  well.  He  came  afterwards  several  times  to  consult  me, 
and  was  bled  occasionally.  I  saw  him  once  more  in  1822.  1 
found  that  he  had  abandoned  his  laborious  occupation  of  gar- 
dener, and  had  an  easy  place  as  the  servant  of  a  priest.  Since 
his  change  of  situation  he  has  been  much  easier :  but  his  former 
symptoms  still  exist,  although  in  a  slighter  degree. 

Ossification,  and  yet  more  cartilaginous  induration  of  the 
valves  of  the  left  side  of  the  heart,  is  by  no  means  uncommon  in 
a  slight  degree ;  but  it  is  extremely  rare  in  such  a  degree  as  mate- 
rially to  impede  the  circulation,  and  thereby  to  give  indication  of 
its  existence.  This  may  seem  contradictory  of  the  assertion  of 
Corvisart,  who  considers  the  cartilaginous  or  bony  induration  of 


OSSIFICATION    OF    THE    VALVES. 


697 


the  valves,  especially  the  aortal,  as  the  most  common  organic  affec- 
tion of  the  heart.  The  difference  of  opinion,  in  this  case  is,  how- 
ever, only  apparent.  I  by  no  means  consider  ossification  of  the 
valves  as  uncommon.  I  can  even  give  my  own  testimony  to 
the  correctness  of  Corvisart's  opinion,  at  the  time  he  wrote,  hav- 
ing been  his  pupil  during  the  period  in  which  the  greater  number 
of  his  cases  were  collected.  At  that  period,  in  the  space  of  about 
three  years,  I  observed,  in  his  clinic,  more  cases  of  extensive  ossi- 
fication of  the  valves,  than  I  have  done  in  the  whole  twenty 
years  that  have  succeeded.* 

*  It  is  chiefly  in  the  case  of  diseased  valves,  although  by  no  means  exclusively 
in  this  case,  that  those  severe  paroxysms  of  dyspnoea  occur,  which  have  been  de- 
nominated cardiac  asthma.  The  exciting  cause  of  these  paroxysms  may  be  either 
an  excess  or  a  deficiency  of  blood  in  the  vessels  of  the  lungs  arising  from  the 
morbid  condition  of  the  heart :  either  of  these  states  may,  no  doubt  give  rise  to  the 
spasmodic  stricture  of  the  bronchial  muscles  in  which  an  asthmatic  paroxysm 
most  frequently  consists:  and  the  former,  at  least,  may  readily  produce  analogous 
results,  through  the  influence  of  mere  congestion,  without  any  muscular  spasm. 
This  form  of  asthma,  or,  to  speak  more  properly,  of  dyspnoea,  has  been  much 
more  fully  treated  by  Dr.  Hope  than  by  any  preceding  author  ;  and  for  ample 
details  respecting  it,  I  refer  the  reader  to  his  Treatise  on  Diseases  of  the  Heart, 
and  to  the  article  on  Diseases  of  the  Valves  in  the  4th.  vol.  of  the  Cyclopaedia 
of  Pract.  Med.  The  following  extracts  from  this  article,  give  the  more  distinct- 
ive characteristics  of  the  cardiac  asthma  in  its  milder  and  severer  forms. 
•"  The  time  of  the  accession  is  less  regular  than  in  ordinary  asthma,  being  more 
dependent  on  the  state  of  the  heart,  which  is  liable  to  accidental  excitement, 
from  a  variety  of  causes,  at  any  moment.  The  fit,  however,  in  ordinary 
asthma,  is,  on   the  whole,  more  apt  to  supervene   during   the  evening,  or  early 

part  of  the  night The  patient  awakes,  generally  with  a  start,  in  a  fit 

of  dyspnoea,  accompanied  either  with  violent  palpitation,  or  a  distressing  sense 
of  anxiety  in  the  praccordia  and  great  constriction  of  the  chest,  as  if  it  were 
tightly  bound.  He  is  compelled  to  assume  a  more  erect  posture,  and  intensely 
desires  fresh,  cool  air;  the  respiration  is  wheezing,  and  performed  with  violent 
efforts  of  all  the  muscles  of  respiration  both  ordinary  and  auxiliary.  The  in- 
spirations are  high  and  accompanied  with  apparently  little  descent  of  the  dia- 
phragm, and  the  expirations  are  short  and  imperfect.  The  surface  is  chilly, 
the  extremities  are  cold,  and  the  face  is  pale  and  sometimes  livid.  In  cases  in 
which  the  pulmonary  congestion  is  only  temporary,  as  in  hypertrophy,  either 
simple  or  with  dictation,  there  is  no  cough  beyond  a  few  slight  and  ineffectual 
efforts,  producing  little  or  no  expectoration ;  and  in  such  cases  the  fit  subsides  as 
soon  as  the  engorgement  of  the  heart  and  great  vessels  is  relieved,  which  nature 
generally  effects  in  two  or  three  hours  or  less,  by  determining  the  blood  to  the 
surface  and  creating  diaphoresis.  In  some  instances  we  have  known  this  ter- 
mination to  be  regularly  accompanied  with  a  copious  secretion  of  pale  urine 
and  a  purging  alvinc  evacuation.  The  pulse,  though  at  first  full,  strong,  and 
bounding,  may,  during  the  worst  of  the  paroxysm,  become  feeble  and  small, 
and  the  sound  and  impulse  of  the  heart  may  be  diminished ;  and  this  in  cases 
even  of  hypertrophy"  ;  for  the  organ,  being  gorged  to  excess,  is  incapable  of 
adequately  contracting  on  its  contents. 

"  Such  is  the  nature  of  an  asthmatic  fit  when  the  pulmonary  congestion  is 
only  temporary  ;  the  case  is  different  when  it  is  permanent,  as  in  valvular  disease 
and  in  some  extreme  cases  of  dilatation.  For  then,  there  is  often  violent  cough 
in  suffocative  paroxysms,  accompanied  at  first>  with  difficult  and  scanty  expec- 
toration of  viscid  mucus,  but  ending  gradually  in  a  copious  and  free  discharge 
of  thin,  transparent,  frothy  fluid,  occasionally  intermixed  with  blood.  Ihis 
evacuation,  by  disgorging  the  pulmonary  capillaries,  affords  great  relief  to  the 
cough  and  dyspnoea.  As,  however,  the  transudation  of  the  matter  to  be  expec- 
torated into  the  air-passages,  and  its  final  elimination,  are  slow  processes,  par- 


698  OSSIFICATION    OF    THE    VALVES. 

This  is  not  the  only  organic  disease,  of  a  chronic  kind,  which 
exhibits  such  irregularity  of  occurrence  at  different  times.  Among 
others,  cancer  of  the  stomach  has  appeared  to  me  much  less  fre- 
quent, of  late  years.  The  same  is  true  of  different  species  of 
accidental  productions,  usually  denominated  cancer,  a  single  case 
of  which  I  have  not  seen  for  the  last  nine  years,  although  I  had 
done  so  several  times  during  each  of  the  preceding  years.  In 
like  manner  during  the  last  nine  years  I  have  only  met  with  one 
case  of  that  variety  of  incipient  tubercles,  called  miliary  granu- 
lations by  Bayle,  but  which  he  mentions  as  of  common  occur- 
rence. The  same  remark  applies  to  many  kinds  of  nervous  dis- 
eases, such  as  mania,  epilepsy,  common  colic,  and  even  the  pain- 
ter's colic.  I  am  aware  that  the  variations  mentioned  may  some- 
times depend  on  other  circumstances,  unconnected  with  the  actual 
relative  frequency  of  occurrence  of  the  diseases  in  question, — as 
in  the  case  when  either  accident  or  superior  reputation  brings 
more  cases  of  one  kind  to  any  particular  physician  ;  yet  I  am  con- 
vinced that  the  inequality  alluded  to  is  found  too  constant  and  too 
striking  in  hospital  practice,  not  to  depend  on  causes  of  a  more 
general  kind.* 

oxysms  of  this  description  are  much  more  protracted  than  those  of  dry  asthma 
from  hypertrophy.  They  frequently  last  five  or  six  hours,  and  I  have  known 
them  persist,  with  only  occasional  remissions,  for  two,  three  or  more  days. 
During  the  attack,  the  pulse  is  quick,  small,  and  weak,  often  irregular  and 
intermittent.  In  other  forms  of  asthma,  the  circulation  through  the  heart  is 
sometimes  little  disturbed." 

In  the  severer  form  of  what  has  been  termed  cardiac  asthma,  the  dyspnoea  is 
greatly  more  urgent  and  the  sufferings  are  more  extreme.  It  will  be  seen,  how- 
ever, from  the  following  excellent  description  of  this  state  by  Dr.  Hope,  that  it 
is  to  confound  the  legitimate  boundaries  of  disease  to  denominate  the  case  one 
of  asthma. 

"Incapable  of  lying  down,  he  is  seen  for  weeks,  and  even  for  months  to- 
gether, either  reclining  in  the  semi-erect  posture  supported  by  pillows,  or -sit- 
ting with  the  trunk  bent  forwards  and  the  elbows  or  fore-arms  resting  on  the 
drawn-up  knees.  The  latter  position  he  assumes  when  attacked  by  a  paroxysm 
of  dyspnoea — sometimes,  however,  extending  the  arms  against  the  bed  on  either 
side,  to  afford  a  firmer  fulcrum  for  the  muscles  of  respiration.  With  eyes 
widely  expanded  and  starting,  eye-brows  raised,  nostrils  dilated,  a  ghastly  and 
haggard  countenance,  and  the  head  thrown  back  at  every  inspiration,  he  casts 
round  a  hurried,  distracted  look,  expressive  at  once  of  fright,  agony,  and  sup- 
plication ;  now  imploring  in  plaintive  moans,  or  quick,  broken  accents  and  half- 
stifled  voice,  the  assistance  already  often  lavished  in  vain;  now  upbraiding  the 
impotency  of  medicine  ;  and  now,  in  a  fit  of  despair,  drooping  his  head  on  his 
chest,  and  muttering  a  fervent  invocation  for  death  to  put  a  period  to  his  suffer- 
ings. For  a  few  hours — perhaps  only  a  few  minutes — he  tastes  an  interval  of 
delicious  respite,  which  cheers  him  with  the  hope  that  the  worst  is  over,  and 
that  his  recovery  is  at  hand.  Soon  that  hope  vanishes.  From  a  slumber  fraught 
with  the  horrors  of  a  hideous  dream,  he  starts  up  with  a  wild  exclamation  that 
'it  is  returning.'  At  length,  after  reiterated  recurrences  of  the  same  attacks, 
the  muscles  of  respiration,  subdued  by  efforts  of  which  the  instinct  of  self- 
preservation  alone  renders  them  capable,  participate  in  the  general  exhaustion 
and  refuse  to  perform  their  function.  The  patient  gasps,  sinks,  and  expires."— 
(Loc.  Cit.) — Transl'. 

*  I  doubt,  to  say  the  least,  the  correctness  of  the  assertion  of  Laennec,  that 
cancer  of  the  stomach  is  less  common  than  formerly.     I  am  well  aware  that 


OSSIFICATION    OF    THE    VALVES. 


699 


Sect.  III. — Bony  and  cartilaginous  Induration  of  the  in- 
ternal membrane  of  the  Heart. 

The  membrane  which  lines  the  interior  of  the  ventricles  is  so 
very  thin,  that  its  very  existence  has  been  denied  by  some  anat- 

there  are  times  when  an  observer  is  struck  with  repeated  instances  of  the  same 
sort  of  organic  lesion  ;  then  a  long  time  will  elapse  without  any  similar  oc- 
currence :  but  this  is  mere  chance;  and  if  Laennec  had  made  enquiries  of  those' 
who  were  attending  the  other  hospitals,  he  would  not  probably,  have  found 
their  observations  agree  with  his  own  as  to  the  frequency  of  this  disease.  A 
writer  is  always  apt  to  think  the  malady  of  which  he  treats  one  of  the  most 
prevalent  in  the  world. 

As  to  his  subsequent  remark,  concerning  the  greater  frequency  of  the 
painter's  colic  that  prevails  at  certain  times,  I  concur  with  him  :  but  I  cannot 
•  agree  that  the  cause  of  this  variation  of  frequency  is  unknown.  I  have  always 
found  it  to  be  the  different  manner  of  working  among  the  laborers  who  are 
employed  in  preparing  lead.  There  is  no  doubt  that  diseases  and  their  symp- 
toms are  considerably  modified  by  causes  yet  unknown  to  us,  and  which  give 
rise  to  the  various  medical  constitutions,  the  existence  of  which  cannot  be  denied. 
The  cholera  is  the  result  of  one  of  these  causes.  Yet  care  must  be  taken  not 
to  abuse  this  expression,  and  regard  it  as  allowing  us  to  neglect  our  researches 
into  all  the  circumstances  which  may  exert  an  influence  in  the  development  of 
a  disease.  If  at  a  future  day  these  circumstances  should  become  fully  known, 
the  vague  and  controverted  expression  medical  constitution,  must  be  discarded. 

DEFICIENCY  OF  THE  VALVES  OF  THE  HEART. 

Diseases  of  the  valves  of  the  heart  obstruct  the  circulation  and  become  the 
cause  of  aneurism  in  that  organ,  not  merely  by  impeding  the  free  issue  of  the 
blood  from  the  cavities.  There  is  another  case  not  observed  before  the  time  of 
Laennec,  in  which  the  valves  are  affected  in  sucli  a  manner  .that  they  are  una- 
ble to  prevent  the  reflux  of  the  blood  into  the  cavity  from  which  it  has  just 
issued:  they  become  deficient  as  to  the  function  which  they  are  designed  to 
execute.     Whence  the  above  name  of  the  disease. 

Divers  alterations  may  obstruct  the  perfect  closing  of  the  valves  and  cause 
this  malady,  particularly  the  following. 

1.  The  malformation  of  the  valves,  either  by  the  thickening  and  induration 
of  their  tissue,  or  by  a  deposit  of  cartilaginous  or  osseous  matter  in  them. 
They  often  change  their  dimensions:  their  free  edges  do  not  touch,  and  some- 
times they  become  immovable,  or  at  least  very  imperfect  in  their  movement. 

2.  The  contraction  of  the  tendons  leading  from  the  fleshy  columns  to  the 
mitral  or  tricuspid  valves.  This  rare  case  has  been  seen  and  described  by  Dr. 
Hope. 

3.  Vegetations  on  the  face  of  the  valves,  particularly  near  the  free  edges, 
obstructing  their  movement  and  preventing  their  perfect  closure. 

4.  A  decay  of  the  free  edges,  caused  by  acute  or  chronic  endocarditis. 

5.  The  perforation  of  the  valves  in  one  or  more  points,  thus  allowing  the 
blood  to  pass  through  them. 

6.  Rupture  of  the  valves,  which,  like  the  preceding,  I  have  always  found  to 
proceed  either  from  an  ulceration  commencing  on  one  of  the  surfaces  of  the 
valves  and  sinking  deeper,  or  from  a  softening  and  increased  friability  of  the 
tissue  of  the  valves. 

7.  The  adhesion  of  one  or  more  of  the  sigmoid  valves  to  the  inner  surface  of 
the  artery  to  which  they  belong.  I  have  never  found  this  lesion  in  the  pulmo- 
nary artery,  but  several  times  in  the  aorta.  The  valves  which  adhere  cannot 
rise  at  each  diastole  of  the  left  ventricle,  and  the  ventricle  at  each  dilatation 
allows  the  blood  to  return  which  it  had  thrown  out  at  the  preceding  contraction. 
I  have  known  cases  where  the   whole  of  the  valve  was  thus  kept  motionless 


700  OSSIFICATION    OF    THE    VALVES. 

omists.  In  the  state  of  disease,  however,  it  becomes  distinctly 
evident,  and  is  easily  demonstrated  by  dissection.     It  is  common 

upon  the  aorta.  More  often  I  have  found  the  adhesions  only  in  one  or  two 
points,  and  formed  by  strings  of  various  lengths.  In  these  cases,  how  can  we 
mistake  the  evidences  of  inflammation  ? 

8.  An  enlargement  of  the  arterial  orifices.  This  cause  I  think  rather  imagi- 
nary than  real.  In  fact,  where  the  arteries  which  lead  from  the  ventricles  of 
the  heart  enlarge,  the  sigmoid  valves  must  enlarge  in  proportion  :  they  cannot 
in  such  a  case  become  deficient. 

9.  A  congenital  malformation  of  the  orifices  of  the  heart,  or  the  valves  which 
border  them.  This  malformation  may  be  such  that  these  folds  in  becoming 
erect,  do  not  join  their  free  edges.  Such  cases,  though  uncommon,  yet  have 
been  observed. 

The  deficiency  of  the  valves,  from  the  causes  above  specified,  has  been 
remarked  at  the  different  orifices  of  the  heart,  more  often  on  the  left  side  than 
on  the  right,  as  may  be  said  of  all  diseases  of  this  organ  arising  from  inflam- 
mation of  its  inner  membrane. 

The  valves  of  the  heart  can  never  become  deficient  without  giving  rise  to 
certain  phenomena  which  may  be  easily  forseen  by  theory,  and  verified  by 
experience. 

First,  if  any  cavity  of  the  heart  receive  during  its  dilatation,  in  consequence 
of  valvular  deficiency,  a  portion  of  the  blood  just  thrown  out,  in  addition  to  the 
normal  supply,  the  walls  of  this  ventricle  must  necessarily  contract  with  more 
quickness  and  power  to  expel  this  excess  of  blood.  Thus  the  heart  becomes 
gradually  hypertrophied,  and  its  cavities  enlarge  precisely  as  when  a  contrac- 
tion of  one  of  the  orifices  causes  the  heart  to  exert  a  stronger  effort  to  expel 
completely  the  blood  contained  in  the  cavity  over  this  orifice.  Valvular  defi- 
ciency therefore,  must  produce  sooner  or  later,  the  divers  accidents  which 
attend  either  hypertrophy  of  the  walls  of  the  heart,  or  enlargement  of  its- 
cavities  with  contraction  of  the  arterial  or  auriculo-ventricular  orifices. 

Further,  this  deficiency  causes  other  phenomena  peculiar  to  itself,  which 
phenomena  may  aid  the  diagnosis  of  the  disease.  These  may  be  observed 
either  in  the  region  of  the  heart,  or  in  the  arteries. 

The  bellows-sodnd  is  heard  in  the  heart:  the  moment  and  place  of  the  sound 
may  indicate  the  orifice  whose  valves  are  deficient.  If  the  bellows-sound  be 
perceived  during  the  first  of  the  two  sounds  which  are  heard  at  each  beating  of 
the  heart,  the  deficiency,  if  there  be  any,  is  in  the  mitral  or  tricuspid  valves. 
If  it  be  heard  during  the  second  sound,  the  deficiency  is  in  the  sigmoid  valves. 
This  supposes  that  other  signs  give  evidence  of  the  deficiency,  for  the  bellows- 
sound  may  accompany  many  other  lesions. 

The  theory  of  the  production  of  the  bellows-sound  by  valvular  deficiency  ex- 
plains its  manifestation  at  the  moments  above  indicated.  We  cannot  in  fact, 
account  for  a  bellows-sound  in  such  cases  but  by  supposing  the  blood,  in  enter- 
ing the  ventricles  or  auricles,  contrary  to  its  custom,  to  cause  a  friction  by 
traversing  the  valves  backward.  If  then,  the  deficiency  is  in  the  valves  border- 
ing the  auriculo-ventricular  orifices,  the  blood  will  flow  back  into  the  auricles 
during  the  systole  of  the  ventricles.  Consequently  the  bellows-sound  will  be 
heard  during  the  moment  of  the  first  sound  of  the  heart,  either  faint  and  marking 
only  the  latter  part  of  the  contraction  of  the  ventricle,  or  loud,  and  covering 
the  whole  of  the  first  sound  of  the  heart.  If,  on  the  contrary,  the  deficiency 
exists  in  the  arterial  valves,  the  blood  will  rush  from  the  aorta  or  the  pulmonary 
artery  into  the  ventricles  during  the  diastole,  and  consequently  the  bellows- 
sound  will  be  heard  during  the  second  sound  of  the  heart.  There  may  be  com- 
plex cases,  such  as  where  two  orifices  at  a  time  are  deficient;  or  where  at  the 
same  time  that  the  sigmoid  valves  are  deficient,  the  mitral  valve  or  the  orifice 
which  it  borders,  has  become  altered  in  such  a  manner  as  to  hinder  the  blood 
from  flowing  freely  into  the  left  ventricle.  In  these  cases,  a  double  bellows- 
sound  may  arise. 

The  locality  of  ihe  sound  is  another  important  circumstance  in  determining 
at  which  orifice  the  deficiency  exists.  M.  Roger,  of  La  Charite,  has  ascertained 
several  facts  which  show  that  when  the  bellows-sound  is  heard  only  at  the  point 


OSSIFICATION    OF    THE    VALVES. 


lOl 


enough  to  find  this  membrane  slightly  and  irregularly  thickened 
on  a  part  of  the  walls  of  the  left  ventricle,  particularly  around  the 
orifices.  In  these  places  it  acquires  a  certain  degree  of  opacity, 
and  such  a  milky-white  or  slightly  yellow  color,  as  renders  it 
very  perceptible.  The  texture  of  the  diseased  portions  is  like  that 
of  cartilage  but  less  consistent.  In  these  cases  I  am  of  opinion 
that  the  indurations  are  not  owing  to  an  actual  thickening  of  the 
membrane,  but  to  the  formation  of  an  imperfect  accidental  carti- 
lage of  a  flattened  form,  between  the  adherent  surface  of  the 
membrane  of  the  muscular  fibres  of  the  heart.  This  position  of 
the  accidental  productions  of  this  kind,  whether  cartilaginous 
or  bony,  which  I  have  termed  incrustations,  appears  to  be 
the  result  of  a  general  law  applicable  to  the  development  of 
all  the  bodies  of  this  kind  met  with  on  the  surface  of  other  mem- 
branes and  the  organs  they  invest,  such  as  the  pleura,  peritoneum, 
lungs,  spleen,  the  arteries,  &c.  Even  the  incrustations  of  the 
valves  of  the  heart  seem  to  originate  in  the  duplicatures  of  these ; 
and  in  their  earlier  stage,  we  can  separate,  in  some  places,  the 
inner  membrane  from  their  surface.  This  I  have  also  sometimes 
effected  in  the  case  of  thickening  of  the  lining  membrane  of  the 
left  ventricle.  I  have  never  found  the  indurated  portions  of  this 
membrane  arrived  at  the  state  of  bone  ;  but  Criiwell's  case,  already 
mentioned,  appears  to  furnish  an  instance  of  the  kind,  and  some 
others  have  been  recorded,  but  not  very  accurately.  Kreysig 
gives  one  unquestionable  instance  (Vol.  hi.  p.  43.)  When  we 
come  to  consider  the  similar  case  of  incrustations  of  the  aorta,  we 
shall  state  what  is  known  relative  to  their  production. 

of  the  heart,  and  during  the  contraction  of  the  ventricles,  it  is  the  mitral  valve 
which  is  deficient.  If,  on  the  other  hand,  the  sound  is  heard  toward  the  base  of 
the  heart,  and  always  during  the  systole  of  the  ventricle,  there  is  more  proba- 
bility of  a  contraction  of  the  aortic  orifice.  In  the  same  manner,  the  bellows- 
sound  at  the  point  of  the  heart  during  the  ventricular  diastole,  would  indicate 
rather  a  contraction  of  the  auriculo-ventricular  orifice. "  When  it  is  heard 
toward  the  base  of  the  heart  during  the  same  diastole,  it  shows  a  deficiency  of 
the  aortic  valves. 

The  examination  of  the  cavities  may  afford  signs  to  discover  valvular  defi- 
ciency, particularly  in  the  valves  of  the  aorta.  All  these  arteries,  those  at  least 
of  large  calibre,  as  the  carotid,  humeral  and  femoral,  exhibit  pulsations  more 
perceptible  to  the  eye  than  common.  If  the  finger  be  applied,  the  strokes  are 
felt  to  be  very  strong  and  vibrating.  They  are  also  more  rapid  than  ordinary- 
On  applying  the  stethoscope  over  the  course  of  the  aorta,  along  the  sternum  and 
the  vertebral  column,  or  over  the  carotids  and  other  superficial  arteries  of  the- 
limbs,  a  very  distinct  bellows-sound  is  heard.  This  sound  is  confined  to  the  as- 
cending aorta,  the  carotid  and  sub-clavian  arteries. — Andral. 


702  POLYPI  OF  THE  HEART. 


CHAPTER  XIX. 

OF    CONCRETIONS    OF    BLOOD,    COMMONLY   TERMED    POLYPI,    OF    THE 
HEART    AND    BLOOD-VESSELS. 

It  was  formerly  customary  to  attribute  to  the  polypous  con- 
cretions of  the  heart  observed  after  death,  the  symptoms  which 
truly  depend  on  the  enlargement  of  that  organ.  The  incorrect- 
ness of  this  opinion  is  proved  by  the  fact,  that  these  concretions 
are  very,  frequently  found  in  persons  who  have  never  exhibited 
any  symptoms  of  disease  of  the  heart :  in  truth,  they  are  met  with 
in  three-fourths  of  dead  bodies.  Perhaps  even  the  existing 
epidemic  constitution  contributes  as  much  to  their  production  as 
the  particular  condition  of  the  individual ;  at  least  I  have  met 
with  them  much  more  frequently,  and  much  larger,  at  certain 
times  than  at  others.  It  is  equally  erroneous  to  believe,  with 
some  modern  authors,  that  polypi  never  begin  to  form  until  after 
death,  or,  as  Pasta  and  Morgagni  thought,  that  they  may  begin  to 
form  merely  in  the  last  struggle.  Many  facts  prove  that  these 
concretions  can  be  formed  during  life.  The  phenomena  of  aneu- 
risms alone  prove  this  ;  and,  besides,  we  sometimes  find  veins  and 
even  arteries  of  considerable  size  completely  obstructed  by  con- 
crete fibrine. 

Haller  found  the  carotid  artery  and  internal  jugular  vein  quite 
obstructed  by  very  firm  concrete  fibrine  in  one  case,  and  the 
inferior  vena  cava  in  another.*  Vinckler,f  Stancari  and  Bona- 
roli,  have  met  with  similar  cases  in  the  vena  cava,  the  emulgent, 
epigastric,  and  iliac  veins.J  I  have  myself  observed,  in  a  con- 
sumptive subject,  an  obliteration  of  the  inferior  cava  for  the  space 
of  four  fingers'  breadth.  This  obstruction  was  produced  by 
a  whitish  fibrinous  concretion  which  filled  the  whole  calibre  of 
the  vein.  The  exterior  layers  of  this  concretion  were  like  the 
buffy  coat  of  the  blood,  only  much  firmer,  and  adhered  strongly 
to  the  inner  coat  of  the  vein :  the  inner  portions  were,  on  the  con- 
trary, of  a  yellowish  color,  more  completely  opaque,  and  of 
a  friable  character,  like  certain  kinds  of  cheese ;  and  exactly 
resembling  the  decomposed  fibrine  frequently  met  with  in  aneu- 
rismal  sacs.  I  have  since  met  with  two  cases  precisely  similar, 
except  that  in  these,  the  concretions  were  more  or  less  colored 
by  recently  coagulated  blood  :  this  appearing  to  have  still  circu- 
lated, although  imperfectly,  around  the  coagula,  which  adhered 
to  the  interior  of  the  vein  in  some  points  only.     In  another  case 

*  Opusc.  Pathol,  obs.  23,24.  t  Dissert,  de  Vasor.  lithias. 

X  Morgagni,  Epist.  64. 


POLYPI    OF    THE    HEART. 


703 


I  found  a  similar  obstruction  in  the  carotid  artery  ;  and,  in  a 
third,  1  observed  the  whole  of  the  vessels  of  the  pia  mater,  in  a 
circumscribed  space  about  the  size  of  the  palm  of  the  hand,  in- 
jected with  a  similar  concretion.  None  of  these  individuals  had 
exhibited  symptoms  indicative  of  the  presence  of  such  concretions, 
nor  did  there  exist  any  obstacles  to  the  course  of  the  blood  which 
might  account  for  them :  we  must  therefore  attribute  them  to 
spontaneous  coagulation  of  the  blood,  and  reasoning,  a  priori, 
therefore,  nothing  is  more  probable  than  that  the  blood  may 
coagulate  during  life,  in  the  heart  also ;  more  particularly  at  the 
very  close  of  life,  when  the  circulation  is  performed  only  in  an 
irregular  and  imperfect  manner.  Many  similar  cases  have  been 
recently  recorded,  particularly  by  Hodgson,  Burns,  Kreysig,  and 
Bertin.  M.  Bouillaud  has  published  a  memoir  in  which  he 
proves  that  many  partial  dropsies  are  owing  to  similar  concretions 
in  the  veins  ;*  and  M.  Velpeau  has  recently  presented  to  the 
Academy  of  Medicine  two  remarkable  instances  of  the  same 
kind.  In  one  of  these,  the  vena  cava,  and  several  veins  opening 
into  it,  were  filled  with  a  concretion  only  slightly  attached  to 
their  sides,  yet  partially  organized,  and  containing  small  enceph- 
aloid  tumors,  which  were  likewise  found  in  other  parts  of  the 
body.f 

Most  of  the  authors  above  mentioned  attribute  the  formation 
of  these  venous  concretions  to  inflammation;  and  Burns  and 
Kreysig  seem  even  to  lean  to  the  opinion  that  the  polypi  of  the 
heart  may  have  the  same  origin.  I  shall  afterwards  examine  the 
grounds  of  this  opinion ;  at  present  I  shall  content  myself  with 
the  fact,  that  the  blood  may  coagulate  in  the  vessels  during  life. 
M.  Corvisart  was,  therefore,  correct  in  distinguishing  polypi  into 
such  as  are  of  a  formation  posterior  to  death,  and  such  as  have 
been  produced  while  the  individual  was  still  alive.  These  two 
kinds  are  easily  distinguished  from  each  other.  The  former,  or 
those  of  recent  formation,  exhibit  merely  a  slight  layer  of  whitish 
opaque  fibrine,  partially  enveloping  the  coagula  of  blood  contained 
in  the  heart  and  large  vessels.  This  fibrine  or  buffy  layer 
never  completely  surrounds  the  coagula,  and  does  not  adhere  to 
the  parietes  of  the  heart  or  vessel  in  which  it  is  contained.  Some- 
times this  layer  is  thicker;  and  in  this  case,  especially  if  the  sub- 
ject is  dropsical,  it  is  semi-transparent  and  tremulous  like  jelly. 
On  the  other  hand,  the  polypi  of  more  ancient  formation  are  of  a 
much  firmer  consistence  (being  nearly  equal  to  that  of  muscle, 
but  with  less  force  of  cohesion)  and  adhere  more  or  less  strongly 

*  Archiv.  gAn.  de  Med.  t.  ii.  and  v. 

t  Revue  Med.  Mai,  Jain  et  Juill.  1826.  Since  then  my  brother  has  published 
in  the  same  journal  (Oct.  1828)  a  case  still  more  striking  than  that  of  M.  Vel- 
peau.— (M.  L.) 


704  POLYPI  OF  THE  HEART. 

to  the  walls  of  the  heart.     In  the  ventricles  and  auricular  sinuses, 
this  adhesion  is  partly  caused,   no  doubt,  by  the  intertexture  of 
the  concretion  with  the  columnar  carnae  ;   but,  even  here,  the 
principal  part  of  the  attachment  is  independent  of  any  mechanical 
structure  of  the  parts.     These  concretions  are  of  a  more  dis- 
tinctly fibrinous  texture  than  are  the  recent  formations  or  the  buny 
coat  of  the  blood,  and  they  are,  further,  of  a  pale  flesh  or  slight 
violet  color  ;  while  the  more  recent  are,  as  already  mentioned,  of 
a  white  or  yellowish  color.     Sometimes,  amid  a  mass  of  inspis- 
sated  fibrine,  we  meet  with  a  small  clot  of  blood,  quite  isolated. 
The  surface  of  the  concretions  is  dotted  with  specks  of  blood, 
which  cannot  be  removed  by  washing :  sometimes  these  penetrate 
only  a  quarter  of  a  line  into  the  polypus,  and  appear  as  if  des- 
tined to  form  the  vessels  afterwards  to  be  developed  in  them  : 
sometimes  they  penetrate  deeper,  and  already  assume  the  aspect 
of  vessels.     Occasionally,   even,  I  have  found   in  these   polypi 
small  coagula  of  blood  of  a  rounded  shape,  and  already  envel- 
oped by  a  distinct  membranous  layer,  evidently  the  rudiments  of 
the  coats  of  a  vessel.     I  have  not  met  with  large  polypous  con- 
cretions in  a  more  advanced  state  of  organization  than  this ;  a 
circumstance  which  is,  no  doubt,  owing  to  their  speedily  proving 
fatal  from  their  size.     We  shall  see,  however,  in  the  chapter  on 
excrescences  in  the  heart,  that  concretions  of  a  smaller  size  may 
attain  a  perfect  organization.* 

These  ancient  concretions  are  found  most  frequently  in  the 
sinus  of  the  right  auricle,  and  in  the  right  ventricle.  When  in 
the  former,  they  completely  obstruct  its  cavity,  but  in  the  ven- 
tricle they  only  double  in  thickness  its  walls,  (thereby  lessening 
its  cavity),  and  obstruct  the  descent  of  the  tricuspid  valve.  In 
this  case,  one  may  remove  all  the  loose  coagulated  blood  without 
injuring  the  concretion ;    it  is  even  possible  that  this  might  be 

*  The  heart  and  the  passages  conducting  to  it  have  sometimes  contained  poly- 
pous concretions  so  far  advanced  in  organization  that  vessels  were  developed 
within  them.  Dr.  Senn  of  Geneva,  relates  a  case  of  a  girl  of  18  years,  who 
had  two  large  tumors,  one  on  the  right  shoulder,  and  the  other  in  the  armpit. 
She  came  to  the  Hotel  Dieu  at  Paris,  and  died  in  three  weeks.  During  her  stay 
at  the  hospital,  it  was  perceived  that  the  right  side  of  the  thorax  and  lace  were 
swelled.  On  dissection,  the  right  auricle  of  the  heart  was  found  nearly  filled 
with  a  concretion,  in  the  midst  of  which  were  vesicles  full  of  a  semi-concrete 
liquor.  This  polypiform  concretion  was  traversed  by  a  multitude  of  vessels 
containing  matter  of  a  bright  red  or  black  color.  It  extended  to  the  superior 
vena  cava,  and  the  right  jugular  and  subclavian  veins,  and  was  in  a  manner 
confounded  with  their  coats  as  by  a  continuity  of  tissue.  It  extended  also  into 
the  right  ventricle. 

Pus  has  also  been  found  in  these  concretions.  We  may  refer  it  to  a  triple 
origin.  It  maybe  absorbed  at  some  distance  from  the  heart,  and  brought  to  that 
organ  in  the  blood.  It  may  be  furnished  by  the  inflammation  of  the  inner  mem- 
brane of  the  heart,  and  afterward  surrounded  by  blood  which  the  presence  of 
the  pus  solidifies.  Or  lastly  the  pus  may  form  in  the  blood  itself  under  the  in- 
fluence of  a  spontaneous  alteration  of  that  liquid.— Andral. 


POLYPI  OF  THE  HEART. 


705 


mistaken  for  the  natural  boundaries  of  the  cavity.  The  columnar 
carnae  to  which  these  concretions  are  attached,  are  commonly 
perceptibly  flattened  ;  a  circumstance  which,  of  itself,  woulti 
prove  their  formation  to  be  anterior  to  death ;  as  a  considerable 
length  of  time  must  necessarily  be  requisite  to  produce  this  effect. 
M.  Corvisart  was  the  first,  as  far  as  I  know,  to  observe  this  flat- 
tening of  the  columnar :  in  the  case  noticed  by  him  they  were 
quite  effaced.*  I  have  not  met  with  any  case  so  strongly  marked 
as  this ;  but  it  is  by  no  means  rare  to  find  cases  wherein  the 
thing  is  very  perceptible.  The  two  kinds  of  concretions  just 
described,  are  clearly  formed  before  death.  The  circumstance 
related  from  Corvisart,  seems  conclusive  on  this  point,  in  respect 
of  the  second  species.  And  in  regard  to  the  first,  we  may  ob- 
serve, that  the  softest  and  most  recent  concretions  are  never  ex- 
actly like  the  bufly  coat  of  blood  abstracted  from  the  vessels. 

There  is  still  a  third  species  of  concretion,  evidently  more  an- 
cient than  those  just  described, — of  a  formation,  perhaps,  several 
months  anterior  to  the  patient's  death.  These  are  found  adher- 
ing to  the  walls  of  the  heart,  sometimes  so  firmly,  as  only  to  be 
detached  by  scraping  with  the  scalpel.  Their  consistence  is  less 
than  that  of  those  just  noticed ;  being  not  at  all  fibrinous,  and 
resembling  rather  a  dry  friable  paste,  or  a  fat  and  somewhat  soft 
cheese.  They  have  lost  the  slight  semi-transparency  of  recently 
concreted  fibrine,  and  resemble  in  every  respect  those  layers  of 
decomposed  fibrine  met  with  in  false  aneurisms.  I  have  only 
met  with  concretions  of  this  kind  on  the  walls  of  the  auricles, 
and  their  sinuses. 

When  the  polypi  of  the  heart  are  of  a  large  size,  I  conceive 
they  may  be  recognized  by  the  stethoscope.  In  several  cases  I 
have  prognosticated  their  existence  from  the  following  signs ; 
which,  nevertheless,  I  dare  not  propound  as  certain,  as  they  are 
not  founded  on  a  great  many  facts : — In  the  case  of  a  patient, 
whose  heart  had  been  acting  regularly,  if  the  pulsations  suddenly 
become  anomalous,  obscure,  and  confused,  so  as  not  to  be  ana- 
lyzed, we  may  suspect  the  formation  of  a  polypus.  If  the  dis- 
ordered action  exists  on  one  side  of  the  heart  only,  we  may  con- 
sider the  thing  as  almost  certain.  For  instance,  if  we  find  the 
pulsations  of  the  heart,  under  the  sternum,  confused  and  tumul- 
tuous, although  the  day  before  they  had  been  regular,  we  may 
look  upon  the  formation  of  a  polypus  in  the  right  cavities  as  very 
probable  ;  and  the  more  so,  if  the  contraction  of  the  left  ventri- 
cle, explored  between  the  cartilages  of  the  fifth  and  sixth  ribs, 
are  more  distinct.f 

*  I  have  seen  the  columns  quite  effaced  where  there  was  no  polypus.—  Transl. 

t  The    polypifbrm  concretions  of  the  heart  arise  from  divers  causes,  which 

cannot  be   fully  understood.     In  some  cases  they  appear  to  be  caused  solely  by 

89 


706  POLYPI    OF    THE    HEART. 

certain  peculiar  conditions  of  the  blood  which  cause  it  to  solidify.  At  other 
times,  causes  altogether  mechanical  seem  to  promote  its  coagulation  in  the  cavi- 
Ijes  of  the  heart.  The  contraction  of  the  orifices  may  do  this  by  obstructing 
the  free  circulation  of  the  blood.  Finally,  inflammation,  which  evidently  coagu- 
lates the  blood  in  the  veins  attacked  by  it,  must  produce  a  similar  effect  when  it 
invades  the  inner  coat  of  the  cavities  of  the  heart. 

The  phenomena  attending  polypiform  concretions  in  the  heart,  will  vary  ac- 
cording as  the  concretion  forms  slowly  or  rapidly.  When  the  concretion  is  slow, 
there  are  no  other  symptoms  than  commonly  attend  a  contraction  of  the  orifices 
of  the  heart.  When  the  concretion  is  sudden,  the  common  symptoms  of  an 
obstruction  of  the  passage  of  the  blood  through  the  heart  appear  at  once.  The 
bellows-sound  is  heard  in  both  cases.  Sometimes  instead  of  this,  a  sharp  his- 
sing sound  is  heard  in  the  region  of  the  heart,  which  seems  to  be  occasioned  by 
a-polypous  concretion.  An  observation  of  this  sort  has  been  published  by  Dr. 
Brouc  in  the  Journal  Hebdomadairc.  In  a  woman  who  died  at  the  Hotel  Dieu 
with  the  ordinary  symptoms  of  disease  of  the  heart,  and  a  sharp  hissing  in  the 
precordial  regions,  he  found  in  the  right  auricle  a  polypous  concretion  adhering 
to  the  tricuspid  valve  and  the  fleshy  columns  of  the  right  ventricle  and  extending 
into  the  superior  vena  cava,  where  it  floated  in  the  form  of  a  white  and  elastic 
cylinder.  Nevertheless,  a  polypous  concretion  in  the  heart  will  always  be  diffi- 
cult to  detect  during  life  :  the  symptoms  being  indistinct,  and  belonging  also  to 
other  diseases. — Andral. 

LITERATURE  OF  POLYPUS  OF  THE  HEART. 

1639.  May,  (Ed.)  A  most  certaine  and  true  relation  of  a  strange  monster  or  ser- 
pent found  in  the  heart  of  John  Pennant,  gent.     Lond.  4to. 

1654.  Pissini,  (Seb.)  Epist.  de  cordis  polypo  (App.  ad  lib.  de  diabete.)  Mediol. 
4to. 

1669.  Malpighi,  (Marc.)  De  viscerum  structura.  de  polypo  cordis.  Lond.  8vo. 

1710.  Gohl,  de  cordis  polypis  ex  neglectis  haemorrhoidibus.  Bert.  4to. 

1724.  Alberti,  (Mich.)  Diss,  de  polypo  cordis.  Hal.  4to. 

1726.  Goetz,  (G.)  De  polyposis  concretionibus  in  pectore.  (Hall.  B.  M.  Pr.  II.) 
Alt.  4to. 

1736.  Hoffman,   (F.)  De  praecavenda  polyporum   generatione   (Opp.  Sup.  ii.) 

Haloz  4to. 

1737.  Pasta,  (And.)  Epist.  de  mortu  sanguinis  et  de  cordis  polypo.  Berg.  4to. 
1742.  Huxham,  (J.,  M.  D  )  Concerning  polypi  taken  out  of  the   hearts  of  sail- 
ors. (Phil.  Trans,  vol.  xlii.)  Lond.  4to. 

1764.  Goetzke,  (J.)  Casus  Med.  Pract.  de  polypo  cordis.  Spirce  4to. 

1776.  Negri,  (         )  Theses  de  polypis  proecordiorum.   Ticini.  8vo. 

1786.  Pasta,  (Jos.)  De  sanguine  et  sanguinis  concretionibus.  Berg. 

1789.  Maincourt,  De   sanguinis  concretionibus  in  corde.  (Doering  I.)   Par.  8vo. 

1800.  Chisholm,  (Col.,  M.  D.)  Account  of  the  epidemic  polypus  of  Grenada  in 

1790.  (Ann.  of  Med.  vol.  v.)  Edin. 
1804.  Tiedemann,  Diss  de  cordis  polypis.     Marb.  8vo. 
1810.  Gartner,  Diss,  de  polypo  cordis  in  specie  infantum  (with  engr.)     Wurceb. 

1817.  Flormann,  Bemerkungen  ueber  polypen  in  herzen.     (Svenska  Handlin- 

gar,  vol.  iv.)     Stockh.  8vo. 

1818.  Nasse,  Zur  kenntniss  der  herzpolypen.     (Horn  Archiv.  Iul.  Aug.  1818.) 

Berl.  8vo. 
1818.  Meckel,  (A.)  Beitrag  zur  lehre  der  herzpolypen.     (Meckel's  Archiv.  No. 

2.)  Berl.  8vo. 
1820.  Meissner,  (F.  L.)  Ueber   die  polypen   in  der  verschiedenen  hohlen,  &c. 

Leips.  8vo. 
1820.  Monfalcon,  Diet,  des  Sc.  M.     (Art.  Polype)  t.  xliv.     Par. 
1827.  Breschet,  Diet,  de  Med.     (Art.  Polype)  t.  xvii.     Par.  8vo. 
1830.  Harty,  (W.,  M.  D.)  On  the  polypi  of  the  heart.  (Dub.  Med.  Trans.  N.  S. 

vol.  i.)  Dub.  8vo. 
1832.  Hope,  Treatise  on  diseases  of  the  heart.     Lond.  8vo. 

Transl. 


INFLAMMATION    OF    THE    INTERNAL    MEMBRANE.  "07 


CHAPTER  XX. 

OF    INFLAMMATION    OF     THE    INTERNAL    MEMBRANE    OF    THE 
HEART    AND    LARGE    VESSELS. 

Inflammation  of  the  inner  membrane  of  the  heart  and  large 
vessels  appears  to  me  to  be  very  rare,  notwithstanding  the  con- 
trary opinion  of  some  modern  observers.  The  correctness  of  my 
opinion  will  appear,  I  think,  from  an  examination  of  the  different 
morbid  appearances,  which  have  been  considered  as  proofs  of  the 
inflammation  in  question.  These  appearances  I  shall  now  notice 
in  order. 

1.  Redness  of  the  membrane. — In  examining  dead  bodies  we 
frequently  find  the  inside  of  the  aorta  and  pulmonary  artery 
uniformly  reddened,  as  if  stained  by  the  blood  they  contained. 
This  coloring  is  of  two  kinds, — either  bordering  on  scarlet,  or 
of  a  brown  or  violet  hue.  Frequently  the  scarlet  color  has  its 
seat  exclusively  in  the  inner  membrane,  as,  when  this  is  removed, 
the  tunic  beneath  is  found  of  the  natural  color :  at  other  times, 
however,  the  redness  penetrates,  more  or  less  deeply,  the  fibrinous 
coat,  and  occasionally  even  reaches  the  cellular.  This  color  is 
quite  uniform,  as  if  painted,  without  any  trace  of  vascularity, 
only  sometimes  more  intense  in  one  place  than  another.  Some- 
times this  stain  diminishes  progressively  from  the  origin  of  the 
aorta,  but  frequently  it  terminates  quite  abruptly  with  irregular 
edges.  Sometimes,  in  the  middle  of  a  very  red  portion,  we  find 
a  circumscribed  spot,  retaining  the  natural  white  color,  like  the 
whiteness  produced  by  pressure  with  the  finger  on  an  erysipela- 
tous skin.  When  the  aorta  contains  very  little  blood,  the  redness 
only  exists  in  the  part  in  contact  with  this,  forming  a  streak  like 
a  ribband.  The  origin  and  arch  of  the  aorta  are  the  situations 
most  commonly  reddened,  and,  with  them,  the  sigmoid  and  mitral 
valves.  Sometimes  nearly  the  whole  arterial  system  presents  the 
same  color.  When  the  pulmonary  artery  is  affected,  its  valves, 
as  well  as  the  tricuspid,  are  commonly  in  the  same  state.  The 
lining  membrane  of  the  ventricles  and  auricles  is  frequently 
colorless,  when  the  valves  are  deeply  stained  ;  not  unfrequently, 
however,  the  auricle  participates  in  the  affection,  and  approaches 
the  color  of  the  valves :  more  rarely  the  ventricle  exhibits  a 
similar  color,  or  rather  browner  or  violet.  Sometimes  the 
auricles  and  ventricles  are  alone  colored ;  and  it  is  worthy  of 
notice  that,  in  this  case,  the  heart  is  found  full  of  blood,  and  the 
arteries  are  nearly  empty.     This  redness  is  attended  by  no  sensi- 


708  INFLAMMATION    OF    THE    INTERNAL    MEMBRANE. 

ble  thickening  of  the  part,  and  it  entirely  disappears  after  a  few 
hours'  maceration. 

Corvisart  has  slightly  noticed  this  affection,  and  has  avowed 
his  ignorance  of  its  nature  and  cause.  Frank,  who  observed  it 
through  the  whole  tract  of  the  arteries,  considered  it  as  the  cause 
of  a  particular  and  uniformly  fatal  fever ;  and  this  opinion  has 
been  adopted  by  Kreysig,  Bertin,  and  Bouillaud.  The  first  and 
most  natural  idea  respecting  the  redness  of  any  part  naturally 
white,  is,  that  it  is  the  result  of  inflammation.  But  mere  redness, 
without  thickening  of  parts,  does  not  sufficiently  characterize 
this  state  ;  while  the  abrupt  termination  and  exact  circumscrip- 
tion presented  by  the  redness  in  certain  cases,  seem  not  easily  to 
accord  with  the  nature  of  inflammation,  and  give  rather  the  idea 
of  impregnation  by  a  colored  liquid,  which  had  been  poured 
irregularly  over  the  membranes,  or  which  had  only  touched  it  par- 
tially, on  account  of  its  small  amount. 

I  am  extremely  doubtful  whether  this  kind  of  redness  gives- 
rise  to  general  symptoms  sufficiently  constant  or  severe  to  indi- 
cate its  presence.  I  have  found  it  in  subjects  who  died  of  very 
different  affections,  and  I  have  never  been  able  to  foretell  its  ex- 
istence by  any  constant  signs.  A  rather  prolonged  agony,  in 
subjects  still  vigorous  yet  cachectic,  from  diseased  heart  or 
otherwise,  has  appeared  to  me  frequently  to  accompany  this 
affection.  In  cases  of  this  kind,, the  blood  is  never  strongly 
coagulated,  and  the  body  most  commonly  affords  marks  of  de- 
composition. 

The  second  species  of  redness  of  the  large  vessels  has  a  quite 
different  appearance,  being,  in  place  of  a  bright  red,  of  a  violent 
or  brownish  hue.  Jt  is  also  usually  extended  at  the  same  time 
to  the  aorta,  pulmonary  artery,  valves,  auricles,  and  ventricles. 
This  variety  is  not  so  exactly  confined  to  the  lining  membrane ; 
as  we  find  the  muscular  substance  of  the  auricles  and  ven- 
tricles, and  even  the  fibrinous  coat  of  the  aorta  and  pulmonary 
artery,  participating  in  it,  at  least  partially. '  I  have  more  partic- 
ularly found  this  variety  of  coloring  in  subjects  who  died  of 
putrid  fevers,  emphysema  of  the  lungs,  and  disease  of  the  heart. 
All  these  individuals  had  remained  long  in  a  moribund  condi- 
tion, with  great  dyspnoea :  in  all,  the  blood  was  very  fluid,  evi- 
dently altered,  with  signs  of  premature  decomposition  in  the 
body.  It  is  accordingly,  most  frequently  in  summer  that,  we  meet 
with  this  condition  of  parts,  and  in  subjects  that  have  been  dead 
upwards  of  twenty-four  hours.  Both  kinds  of  redness,  particu- 
larly the  last,  are  accompanied  with  a  greater  or  less  degree  of 
softening  of  the  heart,  and  an  increased  humidity  of  the  arterial 
tuaics, — the  consequence,  most  commonly,  of  incipient  putrefac- 
tion. 


INFLAMMATION    OF    THE    INTERNAL    MEMBRANE. 


709 


Bouillaud  and  Bertin  have  adopted  the  opinion  of  Frank  re- 
specting the  inflammatory  character  of  the  arterial  redness  ;  and 
yet,  if  we  examine  the  numerous  cases  adduced  by  them  in  sup- 
port of  this  opinion,  we  shall  find  them  very  conformable  with 
the  observations  made  above.  Of  twenty-four  cases,  eleven  were 
severe  continued  fevers,  or  other  affections,  in  which  there  existed 
a  manifest  putridity  of  the  fluids  ;  and  the  other  thirteen  were  al- 
most all  consumptive  patients.  In  the  latter  cases,  the  condition 
of  the  blood  is  most  commonly  not  noticed  ;  but  it  has  been  gen- 
erally remarked,  that  the  redness  in  question  has  seemed  coinci- 
dent with  a  remarkable  degree  of  fluidity  of  the  blood.  Tt  is  also 
worthy  of  notice,  that  most  of  these  dissections  were  performed 
in  summer,  and  upwards  of  thirty  hours  after  death. 

Having  been  struck  with  this  coincidence  of  redness  of  the 
membratie,  and  alteration  of  the  fluids,  and  incipient  decomposi- 
tion of  the  body,  I  began  to  doubt  (four  years  since)  whether 
the  former  were  not  merely  the  result  of  imbibition  of  blood  after 
death.  With  the  view  of  determining  this  point  I  made  the 
following  experiment,  which  I  have  since  repeated  a  great  many 
times.  In  a  subject,  which  exhibited  at  the  time  no  mark  of 
decomposition,  and  in  which  the  aorta  was  healthy  and  white 
throughout,  I  removed  this  vessel,  filled  it  with  blood  from  the 
body,  and  having  passed  a  ligature  round  its  two  extremities, 
deposited  it  in  the  stomach  of  the  subject.  At  the  expiration  of 
twenty-four  hours,  I  laid  the  artery  open,  and  found  its  internal 
tunic  precisely  of  the  scarlet  color  above  described,  and  which 
was  not  lessened  by  repeated  washings.  This  experiment  does 
not  always  succeed  so  completely.  If  the  blood  employed  is  too 
much  coagulated,  the  imbibition  is  obtaiaed  with  much  difficulty, 
feebly  and  slowly.  If  we  employ  blood  but  half-coagulated,  and 
particularly  such  as  we  express  from  the  lungs,  we  produce  the 
scarlet  color.  If  we  employ  blood  which  is  very  fluid,  especi- 
ally if  mixed  with  serum,  we  obtain  a  more  or  less  deep  purple 
or  pale  color.  If  we  fill  the  artery  only  one-half  or  one-quar- 
ter, the  part  in  contact  with  the  blood  alone  exhibits  the  disco- 
loration. If  the  coats  of  the  artery  are  firm  and  elastic,  the  ex- 
periment succeeds  with  difficulty,  and  after  a  long  time,  (72 — 
80  hours,)  and  the  tinge  is  never  deep.  On  the  other  hand,  if 
the  tunics  are  soft,  supple  and  humid,  the  coloring  is  speedily 
diffused  through  their  whole  depth.  The  experiment  succeeds 
much  better  in  summer  than  winter,  and  the  more  readily,  as  the 
decomposition  is  rapid  ;  the  colorization,  however,  is  complete, 
long  before  the  aorta  yields  any  disagreeable  smell. 

Boerhaave  and  Morgagni  (Ep,  xxyi.  36)  were  acquainted  with 
these  kinds  of  redness,  and  attributed  them  to  the  congestion  of 
blood  in  the  last  stage  of  diseases,  accompanied  with  much  dys- 


710  INFLAMMATION    OF    THE    INTERNAL    MEMBRANE. 

pnoea.  Hodgson  has  remarked,  that  the  redness  of  the  arteries 
seems,  in  many  cases,  to  be  the  result  of  a  simple  tincture,  as  we 
frequently  find  spots  of  a  deep  red  color  in  the  parts  correspond- 
ing to  a  coagulum  of  blood.  He  adds,  that  the  same  appearance 
is  observed  in  arteries  that  have  been  long  exposed  to  the  air  in 
the  dissecting  room.  This  last  observation  is  perfectly  correct,  but 
applies  to  a  quite  different  circumstance.  Every  white  tissue  ex- 
posed in  a  humid  place  assumes  a  red  color,  although  never  of 
the  depth  above  described.  This  will  happen,  in  the  course  of 
twenty-four  hours,  to  the  mucous  membrane  of  the  stomach  and 
intestines,  the  peritoneum,  pleura,  &c*  But  in  this  case  the  phe- 
nomenon depends  evidently  on  the  transudation  of  the  blood 
contained  in  the  capillaries  ;  and  the  effect  can  be  promoted  by 
gently  scraping  the  surface  of  the  membrane  with  the  scalpel. 

From  what  goes  before,  I  think  we  must  conclude,  that  the 
redness  of  the  lining  membrane  of  the  heart  and  large  vessels, 
cannot,  in  any  case,  be  considered  as  proving  the  existence  of 
inflammation ;  on  the  contrary,  that  we  may  consider  it  as  being 
the  result  of  a  process  taking  place  in  the  dead  body,  or  in  the 
last  agony,  in  every  case  wherein  we  find  it  coinciding  with  a 
prolonged  and  suffocative  agony — a  manifest  change  in  the  fluids, 
— and  a  more  or  less  marked  state  of  decomposition.  This  is  a 
state  of  parts  to  which  I  wish  particularly  to  call  the  attention  of 
pathologists,  so  that  they  may  avoid  confounfling  the  causes  with 
the  effects  of  diseases.  The  discrimination  of  the  congestion  of 
the  capillaries  from  inflammation  is  often  difficult,  but  it  is  of  the 
utmost  importance  that  it  should  be  made.  In  the  case  now  in 
question,  we  may  be  justified  in  suspecting  inflammation,  when 
the  redness  is  accompanied  with  swelling  and  thickening  of  the 
part,  and  with  an  extraordinary  development  of  capillaries  in  the 
middle  coat  of  the  vessel ;  but  I  am  not  sure  that  even  these 
characters  united  would  prove  the  existence  of  inflammation  in 
the  case  of  a  body  that  was  considerably  oedematous.* 

2.  Pseudo-membranous  exudation. — The  formation  of  a  layer 
of  coagulable  lymph  on  the  inner  surface  of  the  heart  and  vessels, 
is  the  most  unequivocal  sign  of  inflammation  of  this  membrane ; 
and,  indeed,  with  the  exception  of  ulceration,  is  the  only  certain 
one.  Several  instances  of  this  kind  have  been  observed  of  late 
years.  Baillie  found  the  tricuspid  valves  affected  in  this  manner. 
Farre  met  with  a  similar  affection  in  the  aorta  of  a  person  who 
had  died  of  pleurisy  and  pericarditis.  Burns  observed  a  layer  of 
lymph  on  the  inner  surface  of  the  right  auricle  in  one  instance, 

For  some  valuable  observations  and  experiments  on  the  subject  of  redness 
of  the  inner  coat  of  the  blood  vessels,  I  refer  to  a  Memoir  of  MM.  Rigot  and 
Trousseau,  in  the  Archieves  gin.  de  Mid.  t.  xii.  The  result  of  the  researches  of 
these  gentlemen  corroborates  the  views  of  M.  Laennec.—  Transl. 


INFLAMMATION    OF    THE    INTERNAL    MEMBRANE.  711 

and  in  the  left  auricle  in  another.  In  a  third  case,  this  author 
observed,  a  little  above  the  mitral  valve,  "  a  tendinous  septum, 
partially  ossified  and  perforated  in  its  middle  by  an  opening  with 
wrinkled  edges,  capable  of  admitting  the  little  finger."  This 
partition  was  parallel  with  the  mitral  valve,  divided  the  auricle 
in  two  portions,  and  could  only  be  considered  as  the  product  of 
inflammation.  Bertin,  in  the  case  of  a  man  affected  with  hyper- 
trophy and  pericarditis,  found  the  lining  membrane  of  the  aorta 
reddened  and  covered  with  a  half  coagulated  and  reddish  pellicle 
of  albumen  (obs.  ii.)  I  have  myself,  in  like  manner,  occasionally 
observed  false  membranes  of  small  extent,  strongly  attached  to 
the  walls  of  the  auricles,  in  subjects  affected  with  other  diseases 
of  these  organs,  particularly  excrescences.  Liquid  pus  has  never 
been  found  in  the  heart  and  arteries,  except  in  the  case  of  ulcera- 
tion, and  then  only  in  very  small  quantity.  And  indeed  it  is  not 
easy  to  conceive  how  this  could  be  otherwise,  considering  the  ra- 
pidity of  the  circulation,  which  must  carry  off  the  pus  as  soon  as 
it  is  formed. 

3.  Ulceration. — The  lining  membrane  of  the  heart  is  so  thin, 
that  we  can*  hardly  admit  its  ulceration,  independently  of  that 
of  the  subjacent  tissue.  Several  cases  of  undoubted  ulcera- 
tion of  the  interior  of  both  arteries  and  veins  are  recorded 
by  authors,  and  particularly  by  Hodgson  and  Kreysig ;  and 
such  examples  would  be  much  more  numerous  if  we  admitted 
all  those  which  have  been  given  as  such,  both  by  ancient  and 
modern  observers.  But  the  majority  of  these  cases  were  evi- 
dently nothing  else  but  the  separation  of  the  bony  incrusta- 
tions of  the  aorta,  which  will  be  noticed  hereafter.  Small 
pustules  full  of  pus  have  been  sometimes  met  with  beneath 
the  inner  membrane  of  the  aorta,  and  which  have  discharged 
their  contents  into  its  cavity ;  and  it  is  probably  in  this  man- 
ner that  the  real  ulcers  of  the  aorta  are  formed,  being  the 
consequence  of  inflammation  of  the  middle  coat  of  the  arteries, 
or  of  the  fine  cellular  substance  which  unites  this  to  the  inner 
coat.  This  seems  the  more  probable  from  the  fact,  that  in  the 
inflammation  of  all  membranes,  pus  is  formed  on  their  external, 
and  not  their  adherent  surface,  as  in  the  case  of  peritonitis,  pleu- 
risy, croup,  &c.  With  these  pustular  eruptions  (which  are  very 
rare)  the  bony  spiculae  of  the  inner  membrane  of  the  aorta,  or 
rather  the  detachment  of  these,  have  been  sometimes  confounded ; 
the  hollow  left  by  their  removal  being  filled  up  by  lymph,  fre- 
quently intermixed  with  phosphate  of  lime.  Frequently  the  edges 
of  these  morbid  spots  are  reddened  to  a  small  distance  round ; 
an  appearance  which  I  am  disposed  to  attribute  rather  to  the 
imbibition  of  blood  than  to  inflammation ;  a  state  which  is  indi- 


712  INFLAMMATION    OF    THE    INTERNAL    MEMBRANE. 

cated  neither  by  the  presence  of  pus,  nor  by  any  local  or  gen- 
eral symptoms. 

4.  Polypous  concretions. — Are  these  the  product,  and,  conse- 
quently, a  proof  of  the  existence  of  inflammation  of  the  inner 
membrane  of  the  heart  and  arteries  ?  Kreysig  has  answered  this 
question  in  the  affirmative  ;  and  Burns  seems  sometimes  inclined 
to  the  same  opinion.  If  this  opinion  is  well  founded,  we  must 
admit  the  gratuitous  hypothesis  that  the  inflamed  membrane  acts 
upon  the  blood,  and  produces  its  coagulation.  We  may  indeed 
conceive  that  the  blood  itself  performs  an  active  part  in  inflam- 
mation ;  that  it  is,  in  fact,  as  the  ancient  pathologists  imagined, 
susceptible  of  inflammation  ;  and,  to  say  the  truth,  I  am  far  from 
rejecting  this  view  of  the  subject,  however  old  and  obsolete,  as 
it  is  much  more  reconcilable  with  many  established  facts,  than 
are  the  modern  theories.  But  these  are  not  the  views  of  Kreysig, 
Burns,  and  others  who  have  adopted  their  opinions.  Their 
theory  seems  to  rest  chiefly  on  the  cases,  in  which  there  is  close 
adhesion  and  continuity  of  substance  between  the  polypous  con- 
cretions and  the  lining  membrane  of  the  heart  and  vessels.  But 
there  are  many  objections  to  their  mode  of  explaining  the  fact  :— 
for  instance  ;  the  intimate  adhesion  mentioned  is  but  seldom  met 
with,  and  only  in  the  most  perfectly  organized  polypi ; — the  very 
great  majority  of  concretions  found  on  dissection,  are  either  quite 
loose  in  the  heart  and  vessels,  or  are  simply  in  contact  with  the 
inner  membrane,  or  interlaced  with  the  columnar  carnae  ;  the 
history  of  the  cases  proves  that  all  the  polypi  were  in  the  first 
instance,  unattached  ; — on  removing  a  small  coagulum  from  the 
orifice  of  a  vein,  which  had  been  recently  opened,  a  small  poly- 
pous concretion  has  followed  it,  and  this  in  the  case  where  no  sign 
of  inflammation  existed ; — it  is  not  in  young  plethoric  subjects, 
full  of  life,  and  eminently  disposed  to  inflammation,  that  these 
concretions  are  especially  found,  but,  on  the  contrary,  in  the  last 
agony  of  different  diseases,  particularly  those  of  a  chronic  kind, 
and  such  as  have  produced  cachexy,  marasmus,  and  great  debil- 
ity, and  which  have  been  accompanied  by  local  or  general  ob- 
stacles to  the  circulation :  that  the  actions  of  the  animal  organs 
are  not  necessary  to  produce  coagulation  of  the  blood,  or  to  sepa- 
rate its  fibrine,  is  proved  by  the  production  of  the  inflammatory 
crust  on  that  evacuated  by  the  lancet ;  and,  lastly,  these  very 
polypi  are  often  found  in  the  heart  and  large  vessels  of  men  and 
animals,  which  have  been  suddenly  destroyed  in  perfect  health. 
On  the  other  hand,  we  can  conceive  two  ways  in  which  an  organ- 
ized polypus  may  become  attached  to  the  parts  with  which  it  is 
in  contact.  In  the  first  place,  it  may  occasion  an  effusion  of 
coagulable    lymph  by  its    own  local  irritation.     It   may  be  re- 


INFLAMMATION    OF    THE    INTERNAL    MEMBRANE.  713 

marked,  in  corroboration  of  this  hypothesis,  that  in  the  case  of 
obstruction  of  the  veins,  the  more  recent  concretions  are  not  ad- 
herent, but  only  those  which  are  proved  by  their  firmness  and 
comparative  dryness,  and  otherwise  changed  condition,  (and  also 
sometimes  by  the  contraction  of  the  vein,)  to  be  of  ancient  for- 
mation. In  the  second  place,  polypous  concretions  formed  before 
death,  are  evidently  possessed  of  life  as  well  as  the  blood,  and 
retain  it  for  some  time  after  extravasation,  a  remarkable  proof  of 
which  I  formerly  noticed  in  the  organization  of  fibrine  in  the 
bronchi  in  a  case  of  haemoptysis. 

Other  examples  of  the  same  kind  are  furnished  in  the  case  of 
effusions  of  blood  on  the  serous  membranes,  all  of  which  prove 
that  fibrine  separated  from  the  blood  and  coagulated,  is  in  the 
living  body  equally  susceptible  of  organization  with  the  coagu- 
Jable  lymph  effused  in  inflammation.  And  it  may  be  here  re- 
marked that  it  is  not  perhaps  satisfactorily  demonstrated,  that 
the  production  of  a  plastic  lymph,  susceptible  of  organization  and 
of  conversion  into  a  tissue  similar  to  that  in  which  it  is  formed, 
necessarily  pre-supposes  the  presence  of  inflammation.  The  re- 
union of  wounds  made  by  a  fine  cutting  instrument,  sometimes 
takes  place  without  any  obvious  signs  of  inflammation.  In  these 
cases,  as  soon  as  the  haemorrhage  has  ceased,  there  supervenes  a 
discharge  of  a  viscid  transparent  lymph,  which  is  evidently  the 
medium  of  union  employed  by  nature ;  and  it  is  worthy  of  notice, 
that,  in  cases  where  inflammation  exists,  the  flow  of  this  lymph 
precedes  it  by  several  hours.  The  greater  number  of  tumors 
of  considerable  size,  which  form  slowly  in  the  lungs,  ovaries,  or 
other  parts  of  the  abdomen,  are  attached  to  the  neighboring  parts 
by  serous  or  cellular  laminae  of  greater  or  less  extent.  These 
laminae,  unquestionably,  in  some  cases  originate  in  local  pleurisies 
or  peritonitis,  but  in  others,  the  closest  and  most  accurate  obser- 
vation can  detect  no  symptom  of  previous  inflammation.  The 
filaments  and  flocculi  of  albumen,  more  or  less  concrete,  occa- 
sionally found  in  the  water  of  the  most  atonic  dropsies,  and  the 
deciduous  membrane  formed  in  the  early  period  of  pregnancy, 
admit,  in  my  opinion,  of  a  similar  explanation.  It  would  be  to 
fall  into  a  strange  abuse  of  words  and  to  adopt  an  unpardonable 
laxity  of  reasoning,  to  find  inflammation  in  every  case  in  which 
we  observe  only  one  of  its  anatomical  characters, — viz.  plastic 
lymph,  susceptible  of  organization.  Future  observation  may, 
probably,  hereafter  ascertain  the  physical  and  perhaps  chemical 
characters  which  distinguish  the  lymphatic  concretions  produced 
by  inflammation,  from  those  which  are  formed  without  it.  In 
the  present  state  of  our  knowledge  I  think  it  may  be  remarked, 
that  those  formed  under  the  influence  of  evident  inflammation 
have  a  considerable  degree  of  firmness  and  nearly  complete 
90 


714  INFLAMMATION    OF    THE    INTERNAL    MEMBRANE. 

opacity  from  their  very  origin,  and  also  a  yellow  color  like  that 
of  pus :  and  it  is  from  these  characters,  as  well  as  from  their 
disposition  to  become  softened  to  the  consistence  of  pus,  when 
they  are  not  converted  into  an  organized  tissue,  that  I  have 
thought  proper  to  designate  them,  in  this  work,  by  the  term  con- 
crete pus. 

From  all  that  precedes  I  think  we  may  deduce  the  following 
conclusions: — 1.  The  remora  of  the  blood,  in  consequence  of 
obstruction  to  its  course,  suffices  in  itself  to  produce  coagulation, 
and  to  determine  the  formation  of  a  coagulum  of  organizable 
fibrine.  Every  cause  capable  of  occasioning  this  remora,  par- 
ticularly mechanical  obstruction  to  the  circulation  and  repeated 
and  prolonged  faintings,  appears  to  me  sufficient  to  produce  this 
effect.  2.  The  coagulation  of  blood  in  the  vessels  seems  to  pro- 
duce in  some  cases,  particularly  in  the  veins,  a  true  inflammation, 
accompanied  by  the  formation  of  a  false  membrane.  3.  It  ap- 
pears certain  that  occasionally,  and  especially  in  the  veins  where 
the  circulation  is  slow,  an  inflammation  of  the  inner  coat  of  these 
may  occasion  coagulation  of  the  blood,  in  the  vicinity  of  the 
lymph  effused  by  the  inflammation.  4.  Pus  absorbed  in  great 
quantity  by  a  vein,  may  in  several  ways  affect  the  concretion  of 
blood — by  rendering  it  less  liquid  from  simple  admixture,— by 
coagulating  it  by  a  chemico-vital  action, — and  by  exciting  in- 
flammation of  the  containing  vessel.*  It  is  well  known  that 
nothing  is  more  common  than  to  find  the  veins  in  the  vicinity  of 
a  cancerous  breast,  or  in  inflammation  of  the  uterus  after  par- 
turition, filled  with  pus,  either  pure  or  mixed  with  blood,  some- 
times fluid,  at  other  times  more  or  less  inspissated,  and  occasion- 
ally of  the  degree  of  consistence  of  the  contents  of  an  athero- 
matous tumor.f 

*  Recent  experiments  made  by  Dr.  Donne  have  shown  that  by  adding  a  quan- 
tity of  pus  to  a  cup  containing  blood,  the  moment  may  be  hastened  when  this 
coagulated  blood  returns  to  a  liquid  state  in  consequence  of  putrefaction.  An- 
other very  interesting  phenomenon  is,  that  six  hours  after  this  mixture,  the 
globules  of  blood  undergo  a  singular  change  ;  and  afterwards,  when  the  blood  has 
completely  liquified,  instead  of  globules  of  blood,  nothing  is  found  but  globules 
of  pus.  The  progress  of  this  metamorphosis  is  curious  :  the  following  is  the 
account  of  Dr.  Donne.  "  The  colored  envelop  of  the  globules  of  blood  begin 
by  wrinkling  and  folding,  while  the  nucleus  grows  opaque  as  if  by  infiltration. 
Next  the  globule  loses  its  oval  and  regular  form  ;  then  the  envelop  breaks  and 
dissolves,  and  the  nucleus  makes  its  appearance  in  the  liquid  exactly  like  a 
globule  of  pus.  In  this  condition  it  is  impossible  to  distinguish  the  globules  of 
true  pus  from  the  others.  All  this  is  done  in  twenty-four  hours  at  most.  But 
further:  this  blood  which  is  altered  and  liquified  by  the  pus,  produces  in  its 
turn,  the  same  effect  upon  other  blood  with  which  it  may  be  mixed.  It  is, 
therefore,  very  probable  that  it  undergoes  a  genuine  purulent  transformation." — 
Am' 

t  Hodgson  and  Travers  have  published  some  cases  of  this  kind,  which  are, 
indeed,  by  no  means  rare.  An  additional  consequence  of  the  presence  of  too- 
much  pus  in  the  blood,  from  venous  absorption,  is  the  production  of  inflamma- 
tion in  different  organs,  and  especially  the  lungs,  which  run  rapidly  into  suppn- 


INFLAMMATION    OF    THE    INTERNAL    MEMBRANE. 


715 


I  conceive  that  we  may,  in  many  cases,  distinguish  during  life, 
the  simple  coagulation  of  blood  in  the  vessels  from  that  which  is 
the  consequence  of  inflammation.  I  on  one  occasion  met  with 
two  cases,  at  the  same  time,  which  led  me  to  entertain  this  opin- 
ion. One  of  these  was  the  case  of  a  woman  affected  with  in- 
flammation of  the  median  vein,  accompanied  by  erysipelatous 
swelling  of  the  fore-arm,  excessive  pain  of  the  part,  high  fever, 
and  other  very  threatening  symptoms.  The  second  occurred  in 
the  person  of  a  magistrate,  who  came  to  consult  me  for  a  slight 
lameness  which  he  had  felt  in  the  left  thigh  and  leg  for  three  or 
four  days.  I  found  the  internal  saphena  hard  as  a  cord,  over 
its  whole  extent,  and  as  large  as  the  little  finger  over  its  superior 
half.  Pressure  produced  hardly  any  uneasiness  ;  and  indeed  he 
had  come  to  see  me  on  foot,  being  desirous  of  trying  the  effect 
of  exercise  on  his  complaint.  Looking  upon  the  case  as  an  ex- 
ample of  coagulation  of  blood  without  inflammation,  I  recom- 
mended one  bloodletting,  rest,  and  friction  of  the  part,  and  I 
found  the  vein  returned  to  its  natural  suppleness  in  the  course  of 
eight  days.  The  woman,  whose  case  I  formerly  mentioned  when 
treating  of  pneumonia,  was  cured  in  like  manner,  in  the  space  of 
a  very  few  days,  by  means  of  tartar  emetic  in  large  doses.  Facts 
of  this  kind  seem  further  to  lead  us  to  believe,  that  blood  coagula- 
ted from  any  cause  whatever,  may  be  returned  into  the  course  of 
the  circulation,  by  the  absorption  of  the  veins,  and  thence  be 
expelled  the  system ;  as  there  seems  to  me  no  other  mode  of 
accounting  for  the  restoration  of  the  circulation  in  the  affected 
vessel.* 

ration.  It  is  from  this  circumstance  that  the  subjects  of  surgical  operations  and 
those  laboring  under  extensive  suppurations,  are  frequently  cut  off  by  perip- 
neumonies,  which,  according  to  the  observation  of  M.  Cruveilhier,  are  usually 
lobular,  that  is,  commencing  in  several  points  at  once.  Thiamin  my  opinion,  is 
the  mode  in  which  we  must  explain  the  occurrence  of  metastasis  of  pus,  at  least 
in  the  majority  of  cases. — Author.  , 

*  This  chapter  I  regard  as  very  correct.  I  think  with  the  author,  that  the 
uniform  redness  sometimes  found  in  the  internal  surface  of  the  heart,  arteries 
and  veins,  does  not  arise  from  inflammation.  It  is  always  found  in  dead  bodies 
that  have  begun  to  putrefy,  but  seldom  till  twenty-four  hours  after  death.  Yet, 
although  it  is  sometimes  found  ten  hours  after  death,  I  do  not  think  this  a  proof 
that  inflammation  is  the  cause.  Some  bodies  begin  to  putrefy  very  quick ;  and 
some  diseases  cause  the  blood  to  discharge  after  death  its  coloring  matter  upon 
any  substance  with  which  it  comes  in  contact.  This  is  the  cause  of  the  prema- 
ture reddening  of  the  internal  surface  of  the  heart  and  other  organs. 

Still  I  do  not  think  the  inflammation  of  the  interior  of  the  heart  altogether 
an  imaginary  disease.  I  have  observed  its  anatomical  character  and  symptoms 
for  a  lo°n«r  time.  I  named  it  internal  carditis,  but  M.  Bouillaud  calls  it  endo-car- 
ditis  which  I  allow  is  a  better  name.  I  think  the  disease  more  common  than 
people  imagine  ;  and  I  have  no  doubt  it  has  great  influence  in  causing  organic 
affections  of  the  heart. 

The  symptoms  of  endo-carditis  vary  a  great  deal.  Sometimes  they  resemble 
those  of  very  acute  pericarditis,  as  great  anxiety,  difficulty  of  breathing,  violent 
palpitations,  acute  pains  in  the  precordial  regions,  feeble,  rapid  and  intermittent 
pulse,  fainting,  <fcc. 


716  EXCRESCENCE'S  ON  THE  VALVES. 


CHAPTER  XXI. 

OF    EXCRESCENCES    ON    THE    VALVES    AND    INTERNAL    WALLS    OF 
THE     HEART. 

There  are  two  very  distinct  varieties  of  this  affection.  The 
one,  first  noticed  by  Riverius*  has  been  described  by  M.  Corvi- 
sart  under  the  name  of  excrescence  of  the  valves ;  the  other, 
which  does  not  appear  to  have  been  hitherto  described,  I  shall 
notice  under  the  name  of  globular  excrescence. 

1.  Warty  Excrescence. — The  first  might  be  very  well  named 
warty  excrescences,  inasmuch  as  they  are  extremely  like  warts,  es- 
pecially those  of  venereal  origin  on  the  parts  of  generation.  Like 
these,  the  excrescences  in  the  heart  sometimes  resemble  small 
strawberries,  in  their  form  and  tuberous  surface ;  at  other  times 
they  are  elongated  into  the  form  of  a  small  cylinder  or  cord,  and, 
occasionally,  they  are  so  short  and  so  crowded  together,  as  merely 
to  give  to  the  parts  on  which  they  are  situated  a  rough  or  rug- 
ged surface ;  more  frequently,  however,  they  are  either  isolated  or 
ranged  in  a  single  line  along  the  loose,  or  the  attached  border  of 
the  valves.  I  have  never  observed  any  longer  than  three  or  four 
lines.  But  we  occasionally  meet  with  them  sufficiently  numerous 
and  voluminous  to  present  a  rough  resemblance  to  the  comb  of  a 
cock. 

But  these  symptoms  arc  not  constant.  Sometimes  the  bellows-sound  occurs, 
also  the  rasp-sound,  «&c. ;  these  are  occasioned  by  the  passage  of  the  blood 
through  cavities  and  orifices  which  have  contracted  in  consequence  of  a  tume- 
faction of  the  inner  membrane  of  the  heart. 

Endo-carditis  may  arise  spontaneously  and  without  any  cause  that  we  can 
discover.  It  may  accompany  acute  articular  rheumatism.  It  may  cause  an 
alteration  of  the  valves,  and  contraction  of  the  orifices  of  the  heart  ;  dilatation 
of  the  cavities,  hypertrophy  and  thickening  of  their  parietes,  &c,  The  lesions 
which  characterize  this  disease  alter  death  are  the  same  that  belong  to  all  other 
inflammations.  In  the  acute  state  of  the  disease,  the  inner  membrane  is  found 
thickened,  tumefied,  friable,  ulcerated,  and  sometimes  covered  with  false  mem- 
branes. These  lesions  are  very  distinct  upon  the  valves  which  I  have  repeat- 
edly found  in  a  high  state  of  engorgement,  and  much  thicker  than  common. 
In  such  cases,  the  blood  in  contact  with  the  inflamed  membrane  coagulates  upon 
it,  as  in  an  inflamed  vein.  Hence  during  life  arise  clots  of  blood  which  may 
either  liquefy  again,  or  grow  into  that  sort  of  vegetation  sometimes  found  on 
the  free  edge  of  the  valves  of  the  heart.  In  the  chronic  state  of  the  disease, 
the  inner  membrane  thickens,  loses  its  transparency,  and  contracts  white  spots, 
analogous  to  those  found  sometimes  in  the  pericardium.  Chronic  endo-carditis 
leaves  strong  marks  of  its  existence  upon  the  valves;  they  lose  their  transpa- 
rency, grow  thick  and  of  a  milky  white  color.  I  think  it  highly  probable,  thai 
the  cartilaginous  or  osseous  depositions  which  they  exhibit  in  many  subjects  are 
often  caused  by  inflammation  of  the  rudimentary  fibrous  tissue  of  these  valves 
Endo-carditis  may  also  cause  adhesions  between  the  valves  and  the  surrounding 
parts,  and  between  the  valves  themselves. — Andral. 

*  Bonet,  Sepulch.  1.  ii.  sect.  viii.  obs.  24. 


EXCRESCENCES  ON  THE  VALVES. 


717 


The  color  of  these  excrescences  is  sometimes  whitish  like  that 
of  the  valves,  and  hardly  so  opaque ;  more  commonly  they  are 
either  wholly  or  in  part  tinged  with-  a  reddish  or  light  violet 
color.  Their  texture  is  fleshy,  like  venereal  warts,  only  of  some- 
what less  firm  consistence  ;  although  this  is  variable.  They  ad- 
here immediately  to  the  subjacent  parts ;  sometimes  so  strongly 
as  to  be  only  separable  by  incision  :  more  commonly  they  are  re- 
movable by  scraping  with  the  blade,  or  even  the  handle  of  the 
scalpel.  In  the  latter  case,  the  excrescences  are  soft,  of  a  yel- 
lowish-white color,  very  humid,  and  somewhat  resembling  fat. 
The  venereal  origin  of  these  excrescences,  entertained  by  Corvi- 
sart,  appears  to  me  very  improbable,  when  we  consider  their  rarity 
and  the  frequency  of  venereal  complaints,  and  when  we  meet  with 
them,  as  we  do,  in  individuals  who,  in  all  probability,  never  had 
this  disease. 

Whatever  may  be  the  remote  cause  of  these  bodies,  the  manner 
of  their  formation  seems  to  be  more  explicable.  In  dissecting 
the  more  voluminous  excrescences,  it  has  always  appeared  to  me 
that  their  texture  was  exactly  like  that  of  the  more  compact  poly- 
pous concretions,  only  firmer.  Frequently  we  observe  in  their 
center  a  purple  or  sanguineous  tint ;  and  sometimes  I  have  even 
found  a  very  small  but  distinct  coagulum  of  blood.  From  these 
circumstances  I  am  led  to  consider  such  excrescences  as  merely 
small  polypi,  organized  by  the  same  process  which  transforms  the 
false  albuminous  membranes  into  true  adventitious  membranes,  or 
into  cellular  substance.*  In  like  manner  as  Corvisart,  I  have  only 
met  with  these  excrescences  in  the  following  situations,  viz.  the 
mitral,  tricuspid,  and  sigmoid  valves,  and  (much  more  rarely)  the 
interior  of  the  auricles,  especially  the  left.  In  general  they  are 
more  common  in  the  left  than  the  right  side  of  the  heart. 

Kreysig  attributes  the  formation  of  these  excrescences  to  in- 
flammation, an  opinion  in  which  he  has  been  followed  by  Bertin 
and  Bouillaud.  Besides  the  reasons  adduced  in  the  preceding 
chapter  against  this  opinion,  it  may  be  further  remarked,  that  if 

*  We  entirely  agree  with  Dr.  Hope  in  considering  this  opinion  of  Laennec, 
as  to  the  origin  of  these  excresences,  as  altogether  unsatisfactory;  and  we  can- 
not state  our  reasons  with  more  effect  than  in  the  words  of  Dr.  Hope.  On  Laen- 
nec's  principle,  "  as  polypi  are  most  common  in  the  right  cavities  of  the  heart, 
vegetations  ought  to  be  so  likewise, — the  reverse  of  which  is  the  fact.  The 
valves,  moreover,  being  perpetually  in  motion,  would  be  the  last  parts  to  which 
albuminous  concretions  would  adhere,  as  it  is  a  stagnant  state  of  the  blood  which 
is  most  favorable  to  their  formation  ;  yet  the  valves  are  the  parts  most  subject  to 
them.  It  is  amidst  the  intricacies  of  the  columnas  earns,  where  the  blood  is 
more  stagnant  than  elsewhere,  that  we  most  commonly  find  real  albuminous  con- 
cretions of  small  size.  Finally,  if  vegetations  were  merely  fibrinous  concretions, 
instead  of  being  rare,  they  ought  to  be  frequent;  for  as  the  circumstances  which, 
on  this  view,  lead  to  their  formation,  are  common  to  all  persons  laboring  nnder 
an  obstructed  circulation,  all,  or  to  say  at  least,  many,  should  be  affccled  with 
them." — (Loc.  Cit.) — Tron'sl. 


718  EXCRESCENCES  ON  THE  VALVES. 

it  were  well-founded,  the  excrescences  in  question  ought  to  have 
for  matrix  and  medium  of  union,  a  continuous  layer  of  false 
membrane ;  a  circumstance  which  is  never  observed  :  the  inner 
membrane  of  the  heart  being  found  without  any  covering  in 
the  intervals  between  them.  Nevertheless,  I  am  far  from  de- 
nying that  a  false  membrane  from  inflammation  may  sometimes 
become  the  depository  of  concretions  of  blood.  Indeed,  the  facts 
formerly  mentioned,  respecting  the  obstruction  of  vessels  from 
inflammation  may  prove  this  ;  and  I  have  moreover  witnessed 
an  instance  of  the  kind  in  the  left  auricle  in  a  case  of  contraction 
of  the  mitral  valve.  About  an  inch  square  of  the  auricle  was  here 
covered  by  a  false  membrane  of  the  consistence  of  a  firm  polypus, 
and  which  was  throughout  deeply  tinged  with  blood.  But  for  the 
very  reason  that  such  a  membrane  is  very  perceptible  when  it  ex- 
ists, we  ought  to  disbelieve  its  presence  when  it  is  not  visible. 
I  cannot  help  thinking  that  there  is  some  analogy  between  the 
formation  of  these  warty  vegetations,  on  the  edges  of  the  valves 
and  along  the  tendons  of  the  pillars,  and  the  crystalizations  that 
take  place  upon  threads  or  other  minute  solid  bodies  placed  in  a 
saline  solution.  At  any  rate,  it  has  been  already  sufficiently  prov- 
ed, in  the  preceding  chapter,  that  the  blood  may  concrete  partial- 
ly, independently  of  all  inflammation,  and  that  the  coagulum  may 
become  organized  and  adhere  to  the  neighboring  parts. 

Corvisart  has  observed  no  particular  sign  characteristic  of 
these  excrescences,  different  from  those  of  contraction  of  the 
orifice  from  other  causes.  In  none  of  his  cases  has  he  ever  no- 
ticed the  purring-thrill,  although  considered  by  him  as  the  only 
pathognomonic  sign  of  such  affections.  I  conceive  that,  unless 
the  excrescences  are  extremely  numerous,  they  ought  very  slightly 
to  affect  the  motion  of  the  valves,  and,  consequently,  that  they 
ought  to  afford  no  sign  of  their  presence.  Moreover,  from  the 
circumstance  of  these  bodies  being  usually  complicated  with  a 
severe  disease  of  the  heart  or  lungs,  their  symptoms  are  some- 
times masked  by  those  of  the  former,  or  the  attention  diverted 
from  them.  But  when  sufficiently  numerous  materially  to  affect 
the  play  of  the  valves  or  obstruct  the  orifices  of  the  heart,  they 
then  become  distinguishable  by  the  signs  which  indicate  ossifica- 
tion of  the  same  parts  ;  except  that  in  the  former  case,  the  pur- 
ring-thrill is  less  distinct,  and  the  sound  of  the  heart's  contrac- 
tions is  more  analogous  to  that  of  the  bellows  than  the  file.  The 
following  cases  will  illustrate  and  confirm  most  of  the  preceding 
statements. 

Case  XLVI. —  Warty  excrescences  of  the  mitral  valve  and 
left  auricle  ;  rupture  of  one  of  the  tendons  of  the  mitral  valve  ; 
hypertrophy  and  dilatation  of  the  ventricles. — A  man,  aged 
about  thirty-five,  came  into  the   Necker  Hospital  in  April  1819. 


EXCRESCENCES    ON    THE    VALVES. 


719 


He  had  been  affected  for  five  months  with  great  dyspnoea  and 
violent  palpitations  on  making  any  considerable  exertion,  stag- 
ings from  sleep,  and  occasional  spitting  of  blood.  For  a  few 
days  he  had  labored  under  a  severe  diarrhoea.  At  the  time  of 
his  admission,  the  countenance  was  tranquil,  with  some  color, 
the  pulse  small,  hard,  and  tolerably  regular,  and  the  respiration 
oppressed.  The  heart  yielded  a  very  dull  sound,  but  a  strong 
impulse  on  both  sides.  The  sound  was  slightly  audible  on  the 
back.  The  contraction  of  the  auricle  was  almost  as  long  as  that 
of  the  ventricle,  and  yielded  the  bellows-sound.  The  purring- 
thrill  was  felt  extremely  distinct  by  the  hand,  over  the  cartilages 
of  the  fifth,  sixth,  and  seventh  ribs  of  the  left  side.  The  bellows- 
sound  was  also  perceptible  in  a  slight  degree  during  the  contrac- 
tion of  the  right  auricle,  but  much  less  so  than  on  the  left  side. 
The  action  of  the  heart  was  somewhat  irregular.  The  jugular 
veins  were  not  swollen.  The  respiration  was  everywhere  percep- 
tible, but  with  a  slight  mucous  rattle  in  some  points. — Diagnosis : 
Hypertrophy  of  both  ventricles ;  contraction  of  the  mitral  valve 
from  excrescence  or  cartilaginous  degeneration. — This  man  died 
on  the  third  day  after  admission. 

Dissection  thirty-two  hours  after  death. — The  pericardium 
contained  a  pint  of  serum,  of  a  deep  yellow  color,  and  intermixed 
with  a  great  many  opaque  white  flakes.  The  heart  was 
double  the  size  of  the  patient's  fist.  The  right  ventricle  was 
very  large,  its  parietes  being  at  least  four  lines  thick,  and  its  co- 
lumnar very  large.  The  tricuspid  valves,  and  the  sigmoid  of  the 
pulmonary  artery,  were  of  a  deep  violet-red  color.  The  right 
auricle  was  sound.  The  left  ventricle  was  one-third  larger  than 
natural,  and  its  walls  were  six  lines  thick,  and  its  columnae  very 
thick.  One  of  the  tendons  affixed  to  the  edge  of  the  mitral  valve 
was  ruptured  about  its  middle.  This  rupture  appeared  to  have 
been  the  consequence  of  progressive  wasting  of  its  middle  part ; 
and  one  of  the  other  tendons  of  the  same  valve  was  unequally  ex- 
tenuated but  still  unbroken.  The  whole  floating  border, of  the 
mitral  valve  was  covered  with  small  excrescences  such  as  I  have 
described,  varying  in  size,  form,  and  consistence.  Altogether 
they  gave  to  the  valve  a  thickened  and  fringed  appearance.  The 
sigmoid  valves  of  the  aorta,  and  the  lining  membrane  of  this  ar- 
tery, were  extremely  red,  and  exhibited  in  this  respect  a  striking 
contrast  with  the  inner  membrane  of  the  ventricle.  The  whole 
inner  surface,  and  indeed  the  whole  parietes,  of  the  left  auricle, 
were  of  the  same  red  color ;  and  below  the  opening  of  the  left 
pulmonary  veins,  and  about  two  lines  from  the  auriculo-ventri- 
cular  opening,  there  was  about  an  inch  square  coated  with  a  con- 
geries of  excrescences  similar  to  those  on  the  mitral  valve,  and 
were  firmly  attached.     The  muscular  substance  of  the  heart  was 


720  EXCRESCENCES  ON  THE  VALVES. 

generally  yellowish  (except  the  left  auricle)  and  of  moderate  firm- 
ness. The  pleura  contained  about  a  pint  of  serum  on  each  side. 
The  lungs  were  sound. 

Case  XL VII.* — Warty  vegetations  of  the  mitr'al  and  aortal 
valves ;  hypertrophy  of  the  heart ;  pulmonary  apoplexy. — A  wo- 
man between  fifty  and  sixty  years  of  age,  came  into  the  Necker  Hos- 
pital in  April,  1817,  affected  with  haemoptysis,  extreme  exhaustion, 
emaciation,  orthopnoea,  and  general  anasarca.  No  account  of  her 
previous  state  could  be  obtained.  The  expectoration  consisted 
partly  of  yellowish  or  chocolate  colored  mucus,  and  partly  of 
blood.  The  pulse  could  hardly  be  felt  on  account  of  the  oedema, 
but  it  was  ascertained  to  be  irregular  and  small,  yet  somewhat 
hard.  Percussion  elicited  no  results  on  account  of  the  flaccidity 
of  the  integuments  ;  no  pulsation  was  felt  in  the  region  of  the 
heart:  the  jugulars  were  slightly  swollen.  The  disease  was 
entered  as  follows:  Slight  pleuro-pneumonia  with  hypertrophy  of 
the  right  ventricle.  She  was  bled  and  took  diuretics,  with  the 
temporary  effect  of  lessening  the  dyspnoea  and  anasarca.  The 
diagnosis  was  afterwards  modified  as  follows :  Hypertrophy  of 
the  left  ventricle :  ossification  or  contraction  of  the  mitral  or 
aortal  valves  1  tubercles  ?f 

Dissection  twenty-four  hours  after  death. — Both  cavities  of  the 
chest  contained  about  a  pint  of  bloody  serum,  each  with  flakes  of 
coagulable  lymph.  The  left  lung  contained  in  different  parts 
of  its  parenchyma  portions  of  a  reddish-brown  color,  firm, 
granular  when  incised,  exactly  circumscribed,  and  surrounded  by 
a  perfectly  crepitous  tissue.  These  indurated  masses  were  not 
at  all  like  those  of  pneumonia,  but  seemed  to  be  the  consequence 
of  a  peculiar  combination  of  the  blood  (strongly  coagulated,  and 
as  if  partially  dried)  with  the  pulmonary  tissue.  In  the  inferior 
lobe  there  was  a  similar  mass,  more  than  a  cubic  inch  in  extent, 
formed  by  three  concentric  layers,  separated  from  each  other  by 
thinner  layers  of  a  tissue  still  retaining  its  original  soft  and  crepi- 
tous character,  but  only  much  redder  than  natural.  The  larger 
layers,  obviously  the  product  of  effused  blood,  were  of  a  dark-red 
color,  granular  when  incised,  very  firm,  fragile,  and  so  dry  that 
it  was  with  difficulty  that  even  a  small  portion  of  clotted  blood 
could  be  expressed  from  them.  One  of  these  layers  was  so  soft  in 
one  point  as  to  resemble  a  clot  of  blood.  The  portions  of  lung 
thus  indurated  yielded,  when  cut  into,  no  moisture,  except  when 

This  case,  originally  published  in  the  first  edition,  in  the  chapter  on  pulmo- 
nary apoplexy,  was  omitted  in  the  second  :  it  is  now  restored,  and  inserted  here 
as  an  example  of  excrescences  in  the  heart,  and  also  as  a  good  case  of  pulmonary 
apoplexy. —  Transl. 

I  The  notes  of  tins  case  having  been  in  part  lost,  I  can  only  give  the  diagno- 
sis recorded,  without  the  ground  on  which  it  was  founded.— Author. 


EXCRESCENCES    ON    THE    VALVES.  '"1 


compressed  or  scraped  ;  while  the  other  parts  of  the  lungs  were 
more  than  ordinarily  imbued  with  a  yellowish  frothy  serum, 
which  escaped  from  them  when  incised.  There  were  a  few 
tubercles.  In  the  right  lung  there  was  one  mass  like  that  in  the 
left ;  and  the  mucous  membrane  of  the  bronchi  was  of  a  deep  red 
color,  in  different  points,  in  both  lungs.  The  heart  was  twice 
the  size  of  the  subject's  hand.  The  walls  of  the  auricles  were 
slightly  thickened,  and  their  lining  membrane  was  easily  sepa- 
rated. The  left  ventricle  could  have  scarcely  held  an  almond  in 
its  shell.  The  fleshy  columns  were  separated  from  each  other 
like  those  of  the  right  ventricle,  and  at  their  origin  the  ventricular 
wall  was  an  inch  and  a  half  in  thickness.  The  edges  of  the 
mitral  valve  were  shriveled  and  slightly  cartilaginous,  and  con- 
tained three  excrescences  about  a  line  in  length,  firm,  and  not 
readily  separated  by  the  handle  of  the  scalpel.  The  right  ven- 
tricle was  somewhat  thicker  than  natural,  and  its  fleshy  columns 
more  conspicuous.  The  aorta  was  so  small  as  hardly  to  admit 
the  little  finger.  Two  of  its  valves  presented  excrescences  similar 
to  those  on  the  mitral,  very  like  certain  syphilitic  warts. 

2.  Globular  excrescence.— The  globular  excrescences  have  an 
appearance  quite   different  from  those  just  described,  resembling 
little  balls   or  cysts,  of  a  spherical  or  oval    shape,  and  of  a  size 
from  that  of  a  pea  to  that  of  a  pigeon's  egg.     Their  exterior  sur- 
face  is  even,   smooth,  and  of  a  yellowish-white   color  ;  and  the 
thickness  of  their  walls  is  very  uniform,  being  never  more  than 
half  a  line.     The  substance  composing  these  is  opaque  and  very 
similar  to  that  of  old  polypi,  its  consistence    being  firmer  than 
boiled  white  of  egg.     Their  inner  surface  is  not  so  smooth  as  the 
exterior,  and  it  appears  to  be  composed  of  a  softer  substance, 
which  occasionally   has  the  appearance  of  passing  gradually  into 
the  matter  contained  within  it.     This   matter  may   exist  in  three 
different  states,  all  of  which  may  be  found  in  the  same  subject, 
but  in  different  cysts.     These  are,  1st,  a  liquid  resembling  half- 
coagulated  blood,  only  turbid  as  if  intermixed  with  some  insoluble 
powder,  and  sometimes  containing  a  few  clots  of  perfectly  coagu- 
lated blood  ;  2nd,  a  more  opaque  matter,  of  a  pale  violet  color  of 
a  pultaceous  consistence,  and  very  like  the  lees  of  wine  ;  and  3d,  a 
yellowish  opaque  fluid,  like  thin  pus  or  thick  paste,  and  evidently 
consisting  of  decomposed  fibrine  like  that  found  in  aneunsmal  sacs. 
1  have°  only  met  with  cysts,  of  this  kind  in  the  ventricles  and 
auricular  sinuses.     They  are  found  as  frequently  in  the  right  as 
the  left  side  of  the  heart,  generally  near  the  apex  of  the  ventricles, 
and   always  adherent   to   the   walls   of  the   cavity.     They   are 
attached  by  means  of  a  pedicle,  which  is  often  so  slightly  con- 
nected  with  the  columnar  carnae  as  to  be  detached  from  them 
without  being  ruptured.     This  pedicle,  although  forming  part  ot 
91 


722  EXCRESCENCES  ON  THE  VALVES. 

the  excrescence,  resembles  the  common  polypi  more  than  the 
other  portions,  and  seems  as  if  it  were  of  more  recent  formation 
and  less  perfectly  organized.  I  have  never  found  these  bodies 
more  organized  than  I  have  described,  and  I  have  considered 
those  containing  clots  of  blood  as  the  newest ;  those  con- 
taining a  fluid  like  the  lees  of  wine  as  next  in  order,  and 
those  containing  a  puriform  matter  as  the  most  ancient.  I  sus- 
pect that  Cruwell's  case,  formerly  mentioned,  was  an  example  of 
this  kind  of  excrescence,  completely  organized  and  arrived  at  the 
state  of  cartilage  or  bone.  I  have  met  with  these  excrescences  in 
subjects  who  had  died  of  different  diseases,  but  all  of  whom  had 
remained  in  a  dying  state  for  several  days  or  even  weeks.  Upon 
examining  the  heart  with  the  stethoscope,  in  these  cases,  I  have 
been  able  to  detect  no  constant  disorder  of  the  circulation  ;  and 
in  some  the  action  of  the  heart  has  continued  regular  to  the  last. 

In  the  Miscell.  Nat.  Cur.  we  find  a  case  of  tumor  of  the  heart 
which  seems  to  have  been  an  example  of  the  excrescences  we  are 
now  considering  ;  and  this,  and  the  case  of  Cruwell,  are  the  only 
ones  I  have  met  with  in  the  older  authors.  The  work  of  Burns 
contains  three  examples  of  this  affection,  in  two  of  which  "  a  mem- 
branous-looking capsule  encircled  the  polypus,  which  was  com- 
posed of  firm  concentric  layers,  and  the  roots  of  which  were  in- 
terwoven among  the  musculi  pectinati."  (p.  194.)  In  a  third  case, 
this  author  met  with  a  similar  vesicle  containing  a  tea-spoonful  of 
perfect  pus.  An  instance  of  the  same  kind  is  cited  from  Baillie  ; 
(Morb.  Anatomy)  and  perhaps  we  ought  to  add  a  fourth  case  by 
Burns,  (p.  202.)  of  a  polypus  attached  to  the  left  auricle,  of  the 
size  of  a  pullet's  egg,  and  partially  ossified. 

The  formation  of  these  globular  excrescences  is  not  easily  ac- 
counted for.  The  first  time  1  observed  them  I  was  reminded  of 
a  remarkable  case  which  I  met  with  during  my  studies,  and  which 
is  recorded  by  M.  Tonnelier,  in  the  Journ.  de  Med.  t.  iv. — A 
young  woman  swallowed  an  ounce'  of  arsenic,  and  recovered. 
A  year  afterwards  she  did  the  same  and  died.  On  examining  the 
stomach,  there  was  found,  beside  the  traces  of  the  arsenic,  a  cyst 
of  the  size  of  a  goose's  egg,  which  appeared  to  have  been  recently 
separated  from  the  vicinity  of  the  pylorus.  In  this  cyst,  which 
was  precisely  like  the  false  membranes  of  an  old  pleurisy,  and 
about  a  line  in  thickness,  there  was  an  ounce  of  erystalized  arse- 
nic, which  must  have  occasioned  an  instantaneous  inflammation, 
and  such  a  secretion  of  coagulable  lymph  as  sufficed  to  envelop 
it.  The  globular  excrescences  have  the  same  form  and  consis- 
tence as  the  cyst  in  question  ;  but  they  contain  no  substance  suf- 
ficiently irritating  to  have  occasioned  inflammation.  We  have 
already  seen,  that  the  more  recent  contain  only  blood  or  concrete 
fibrine  ;  and  the  more  ancient,  what  seems  to  be  pus.     If  pus 


EXCRESCENCES    ON   THE    VALVES. 


723 


were  always  contained  in  these  vesicles,  we  might  imagine  that 
this  might  occasion  inflammation  ;  but  the  contrary  is  the  case, 
and  it  seems  much  more  probable  that  the  pus  is  secreted  by  the 
containing  membrane.  On  the  other  hand,  the  pedicle  by  which 
these  bodies  are  attached  to  the  pectinate  muscles,  is  almost  al- 
ways less  organized  than  the  other  parts,  and  its  very  extremity 
looks  as  if  it  were  only  just  recently  coagulated.  It  would  there- 
fore seem,  that  the  formation  of  the  vesicle  were  long  anterior  to 
the  period  of  its  attachment  to  the  walls  of  the  heart. 

These  globular  excrescences  not  being  as  yet  well  known,  I 
will  here  give  two  examples  of  them,  in  addition  to  one  reported 
in  a  former  chapter. 

Case  XL  VIII. — Globular  excrescences  in  the  right  ventricle, 
in  a  phthisical  subject. — A  woman,  aged  forty,  came  into  the  hos- 
pital on  the  30th  October,  1817,  affected  with  phthisical  symptoms, 
which;  together  with  occasional  faintings  and  palpitations,  had 
existed  for  a  year.  At  the  time  of  her  admission  there  was  con- 
siderable emaciation,  hectic  fever,  frequent  cough  with  copious 
,  expectoration  of  opaque  yellow  sputa.  On  the  18th  of  November, 
at  which  time  the  symptoms  remained  nearly  the  same,  percus- 
sion of  the  chest  gave  a  pretty  good  sound,  everywhere  except  in 
the  region  of  the  heart,  where  the  sound  was  somewhat  dull. — 
The  action  of  the  heart,  under  the  stethoscope,  was  not  healthy, 
the  pulsations  were  too  frequent,  and  often  irregular — two  or 
three  regular  beats  being  followed  by  others  very  quick  and  at- 
tended with  a  sort  of  convulsive  bound.  The  sound  of  the  ven- 
tricular systole  was  dull,  and  the  impulse  either  feeble  or  so  con- 
founded with  the  respiratory  movements  as  to  be  appreciated 
with  difficulty.  There  was  also  distinguishable,  a  sound  resem- 
bling that  produced  by  a  bubble  of  air  escaping  from  a  fluid,  or 
like  the  dash  of  water  shaken  in  a  thin  glass  flask.  Respiration 
was  everywhere  weak,  but  less  distinct  on  the  left  than  on  the  right 
side.  Pectoriloquy  was  not  perceived.  There  was  a  sense  ol 
constriction  in  the  cardiac  region,  and  a  slight  pain  in  the  back, 
immediately  opposite.  Diagnosis  : — Tubercles  in  the  lungs  ;  dis- 
ease of  the  heart,  not  yet  discriminated.  November  29.  Dyspnoea 
somewhat  less.  The  peculiar  sound  above  mentioned,  no  longer 
perceptible.  Contraction  of  the  auricles  and  ventricles  nearly 
equal,  and  the  sound  more  obtuse  than  natural — but  perceptible 
under  the  clavicles : — hypertrophy  with  dilatation  of  the  heart. 
She  died  on  the  5th  December. 

Dissection  twenty-four  hours  after  death. — The  lungs  were 
adherent  to  the  pleura,  and  full  of  tubercles  in  different  stages. 
The  heart  was  larger  than  the  hand  of  the  individual.  The  in- 
terior of  the  right  ventricle  contained  several  small  vesicles  some- 
what larger  than   a  pea  generally,  and   were  of  the  size  of  a 


724  EXCRESCENCES  ON  THE  VALVES. 

small  cherry.     Their  external  surface  was  smooth  and  whitish, 
but  with  a  tint  of  red  here  and  there  :  they  were  all  pediculated 
and  attached  to  the  walls  of  the  ventricles  by  radicles,  (inter- 
woven with   the  columnar  camse,)   the  extremities  of  which  ter- 
minated in  clots  of  blood,   and  had  all  the  characters  of  polypous 
concretions.     The  parietes  of  these  vesicles  were  opaque,  yellow- 
ish, of  a  consistence  somewhat  greater  than  that  of  boiled  white 
of  egg,  and  yet  somewhat  friable,  and  nearly  twice  as  thick  as  the 
nail.     Their  internal  surface  was   not   quite  so  smooth  as  the 
outer,  and  was  deeply  tinted  with  the  contained  matter :  this 
varied  in  different  vesicles,  being  in  some  half-fluid  and  of  the 
color  and  appearance   of  wine-lees,  in   others  of  a   yellowish- 
white,  puriform,  and  of  the  consistence  of  paste  ;  in  others,  again, 
it  was  a  mere  clot  of  blood  mixed  with  a  small  quantity  of  fibrine. 
The  cavity  of  the  right  ventricle  was  a  little  larger  than  natural ; 
its  walls  of  the  proper  thiekness.     The  other  organs  were  sound.* 
Case  XLIX. — Globular  excrescences,  with  hypertrophy  and 
dilatation  of  the  heart  and  pulmonary  apoplexy.     A  man,  aged 
forty-five,  came  into  the  Necker  Hospital,  in  the  end  of  August . 
1818,  having  been  for  several  years  subject  to  great  dyspnoea  on 
using  violent  exercise,  and  this  having  become  permanent  since 
about  a  fortnight  previous  to   his  admission.     At  this  time,  the 
legs  were  cedematous,  the  face  pale,  the  pulse  hardly  perceptible, 
decubitus  on  the  back,  and  the  sleep  short  and  suddenly  inter- 
rupted.    The  respiration,  although   short,  was  distinct  under  the 
stethoscope,  and  percussion  elicited  a  good  sound  except  in  the 
cardiac  region.     The  left  ventricle  gave  a  very  great  impulse,  and 
the  sound  was  loud  ;  the  sound  and    impulse  of  the  right  were 
middling ;  the   sound   of  the  auricles  imperceptible.     In  conse- 
quence, the  diagnosis  was  given — Hypertrophy    of  the  heart. 
Being  better,  he  went  out  of  the  hospital  in  a  month,  but  returned 
about  six  weeks  afterwards,  with   the   same  symptoms  and  signs 
as  before.     The  use  of  the  same  means  (bloodletting,  aperients, 
and  diuretics)  again  relieved   him,  and  he  was   discharged  after 
six  weeks.     He  returned  once  more  on  the   16th  January,  worse 
than  on  former  occasions.     He  could  not  now  lie  down,  and  if  he 
attempted  to  lie  on  his  face,  he  complained  of  a  pulsation  in  the 
throat  opposite  the  sternum.     The  anasarca  was  increased,  and 
there  were  now  cough  and  diarrhoea,  and  also  pain  in  the  prae- 
cordia.     The  impulse  of  the  heart  was  very  great.     The  means 
formerly  used  afforded  no  relief,  and  he  remained  nearly  in  the 
same  state  until  the  3rd  of  February,  when  he  was  seized  with 

*  In  the  above  case  every  thing  leads  to  the  belief  that  the  excrescences  ori- 
ginated at  the  time  the  laintings  and  palpitations  came  on,  that  is,  about  a  year 
before  death.  It  is  evident  that  the  excrescences  in  the  heart  were  the  cause  of 
death  ;  the  phthisis  being  in  too  early  a  stage  to  produce  this  effect.—  Author. 


PERICARDITIS. 


725 


fits  of  extreme  dyspnoea,  with  cough,  &c.  which  were  followed,  on 
the  4th,  with  severe  haemoptysis.     At  this  time  the  chest  sounded 
well,  but  the  respiration  was  indistinct  over  the  lower  part  of  the 
lung,  and  there  was  a  large  mucous  rhonchus  over  nearly  the 
whole  chest.     The  words  "  Hamoptysical  engorgement'1''  were 
now  added  to  the  diagnosis,  and  the  patient  died  four  days  after. 
Dissection  sixty  hours  after  death. — The  heart  was  three  times 
as  large  as  the  fist  of  the   individual.     The  right  ventricle  was 
partially  filled  by  a  polypous  concretion  which  extended  into  and 
completely  filled  the  right  auricle.     This  concretion  was  firm  and 
fibrinous,  in  parts  reddish,  and   here  and  there  striated  as  if  by 
the  rudiments  of  small  vessels.     This  ventricle  was  somewhat 
dilated.     Near  its  apex  there  were  two  or  three  cysts  of  the  size 
and  nearly  of  the  shape  of  beans,  of  a  yellowish-red  color,  at- 
tached between  the  columnae  carnae.     Their  walls  were  strong 
but  thin,  and  they  contained  a  fluid  like  wine-lees.    They  adhered 
to  the  columnae  carnae  by  means  of  pedicles  exactly  like  the 
firmer  portions  of  the  polypus,  and  interlacing  with  the  columnae. 
The  walls  of  the  left  ventricle  were  from  nine  to  eleven  lines  in 
thickness,   and    remarkably  solid.     The  mitral   valve  contained 
several   very  hard  cartilaginous  plates,  but  was  not  altered  in 
shape.     The  valves  of  the    aorta  were  sound ;  and  this  artery 
was  covered,  from  its  origin  to  its  second  curvature,  with  innu- 
merable cartilaginous   and  bony  plates,  and  its  arch  was  dilated. 
The  right  lung,  in  its  upper  three-fourths,  was  reddened  rather 
than  impregnated  with   fresh  blood,  and  was  crepitous.     At  its 
base,  there  was  a  zone  of  two  or  three  fingers'  breadth,  and  in- 
cluding the  whole  thickness  of  the  lung,  of  a  dark-reddish  color, 
as  solid  as   liver  and  of  a  granular  aspect  when  incised  :  it  was 
exactly  circumscribed,  and  terminated  abruptly  in  the  crepitous 
tissue  above  it.     There  were  three  or  four  circumscribed  patches 
of  the  same  kind  higher  up  in  the  same  lung,  not  larger  than  al- 
monds or  walnuts.     The  left  lung  was  much  less  affected  ;  but  in 
the  posterior  part  of  the  inferior  lobe,  it  contained  two  or  three 
circumscribed  masses  exactly  like  those  in  the  right  lung. 


CHAPTER  XXII. 


OF    PERICARDITIS. 


Pericarditis  is  inflammation  of  the  serous  membrane,  which 
lines  the  fibrous  sac  of  the  pericardium,  the  heart  and  origin  of 
the  large  vessels.     It  may  be  either  acute  or  chronic. 


726  PERICARDITIS. 


Sect.  I. — Anatomical  characters  of  Pericarditis. 

1.  Acute  Pericarditis. — This  inflammation,  like  that  of  all 
membranes  of  the  same  kind,  is  marked  by  redness,  more  or  less 
deep,  a  concrete  albuminous  exudation,  and  a  sero-purulent  ef- 
fusion. The  redness  is  almost  always  but  slight  in  the  acute 
disease.  When  it  exists,  it  is  for  the  most  part  only  partially. 
It  is  most  commonly  punctuated,  and  looks  as  if  the  surface  of 
the  membrane  was  covered,  here  and  there,  with  little  specks  of 
blood,  very  close  to  each  other.  I  have  never  perceived  that  this 
redness  was  accompanied  by  any  thickening  of  the  part.  In 
some  cases,  wherein,  to  judge  by  the  thickness  of  the  false  mem- 
branes, the  inflammation  appears  to  have  been  very  great,  no 
redness  whatever  can  be  discovered  on  the  serous  membrane,  on 
removal  of  the  fibrinous  exudation.  This  concrete  albuminous 
exudation  commonly  invests  the  whole  surface  of  the  pericardium, 
as  well  on  the  heart  and  large  vessels,  as  on  the  loose  sac.  It 
rarely  presents  the  appearance  of  an  equable  membranous  layer, 
like  the  false  membranes  of  pleurisy ;  on  the  contrary,  its  surface 
is  most  frequently  marked  by  a  great  number  of  rough  and  ir- 
regular prominences.  Sometimes  the  knobbed  appearance  of  this 
exudation  is  very  like  what  would  result  from  the  sudden  sepa- 
ration of  two  pieces  of  slab,  joined  by  a  pretty  thick  layer  of 
butter  ;  at  other  times,  it  is  more  like  the  internal  surface  of  the 
second  stomach  of  the  calf,  an  observation  made,  in  one  case,  by 
M.  Corvisart.  In  certain  cases  this  aspect  of  the  false  membrane 
has  given  rise  to  a  singular  error,  it  having  been  mistaken  for  a 
variolous  eruption  in  subjects  who  have  died  of  the  small  pox. 
The  consistence  of  the  lymph  is  usually  greater  than  that  of  the 
false  membranes  of  pleurisy ;  it  is  also  thicker,  and  more  firmly 
adherent  to  the  subjacent  parts ;  its  color  is,  however,  the  same, 
being  of  a  pale  yellow  analogous  to  that  of  pus. 

The  serum  effused  in  inflammation  of  the  pericardium  is  limpid, 
of  a  pale  yellow  color,  or  slightly  brownish.  It  contains  few 
fragments  of  semi-concrete  albumen ;  at  least,  it  very  rarely  con- 
tains enough  of  these  to  give  it  a  milky  and  turbid  character. 
The  quantity  of  this  effusion  is  usually  considerable  in  the  com- 
mencement of  the  disease,  often  as  much  as  a  pound.  M.  Cor- 
visart found  it,  in  one  case,  to  amount  to  four  pounds.  It  would 
seem  that  the  quantity  of  effused  serum  diminishes  quickly,  as 
soon  as  the  violence  of  the  inflammation  begins  to  subside  ;  as 
we  usually  find  the  proportion  of  serum  and  of  albumen  nearly 
equal,  while' in  pleurisy  and  peritonitis,  the  serum  is  commonly 
from  twenty  to  fifty  times  greater  than  that  of  the  extravasated 
lymph.     Frequently,  even,  in  very  violent  cases,  we  find  no  ef- 


PERICARDITIS. 


727 


fusion  of  serum,  and  only  a  thick  and  highly  concrete  albumen 
filling  the  whole  cavity  of  the  pericardium,  and  uniting  the  heart 
and  large  vessels  to  the  exterior  or  loose  portion  of  this  mem- 
brane. In  this  case  we  may  suppose  that  the  effused  serum  has 
been  quickly  absorbed,  and  the  two  layers  of  false  membrane 
cemented  together ;  although  it  is  not  impossible  that,  in  some 
cases,  the  more  solid  exuadation  may  be  the  only  one.  We  have 
seen  that  the  same  thing  occasionally  takes  place  in  certain  partial 
and  sub-acute  inflammations  of  the  pleura ;  and  several  obser- 
vations have  led  me  to  believe,  that  the  cartilaginous  patches  that 
sometimes  are  met  with  on  the  exterior  of  the  lungs,  are  pro- 
duced in  the  same  manner.  Sometimes  pericarditis,  like  pleurisy, 
is  hemorrhagic,  in  which  case  the  serum  is  sanguineous,  and  the 
surface  of  the  false  membranes  is  of  a  red  color.  When  the  dis- 
ease terminates  favorably,  the  pseudo-membranous  exudation, 
after  a  certain  time,  is  converted  into  cellular  substance,  or  rather 
into  laminae  of  the  same  nature  as  the  serous  membranes ;  that  is 
to  say,  the  laminae  are  double,  the  exterior  surface  being  exhalent, 
and  the  interior  cellular  or  adherent,  and  containing  the  vessels 
distributed  to  the  part.  Sometimes  these  laminae  are  long,  some- 
times so  short,  that  the  pericardium  seems  intimately  adherent  to 
the  heart. 

Sometimes,  though  rarely,  the  inflammation  is  confined  to  a 
part  only — sometimes  a  very  small  part — of  the  pericardium. 
These  partial  inflammations  are  in  proportion  to  the  general,  in 
point  of  frequency,  hardly  as  one  to  ten.  Their  anatomical  char- 
acters are  precisely  the  same,  only  that  the  albuminous  exudation 
is  in  them  confined  to  the  inflamed  part.  The  serous  effusion  is 
sometimes  as  abundant  as  in  the  general  disease  :  more  common- 
ly, however,  it  is  less.  The  inflammation  in  this  case  almost  al- 
ways terminates  in  being  cured,  by  the  transformation  of  the 
pseudo-membranous  exudation  into  long  serous  laminae  :  scarcely 
ever  are  the  partial  inflammations  followed  by  the  intimate  adhe- 
sion of  the  parts. 

We  often  find  on  the  surface  of  the  heart,  opaque  white 
patches,  sometimes  as  large  as  the  palm  of  the  hand,  more  com- 
monly one-half  or  one-third  this  size,  and  often  very  small.  They 
are  nearly  of  the  thickness  of  the  nail,  and  have  a  degree  of  con- 
sistence equal  to  that  of  the  membranes  composed  of  condensed 
cellular  substance, — such,  for  instance,  as  the  exterior  membrane 
of  the  lymphatic  glands.  They  adhere  so  closely  to  the  parts 
on  which  they  lie,  that  it  is  difficult  to  ascertain,  even  by  dis- 
section, whether  they  are  situated  above  or  beneath  the  fine 
membrane  covering  the  heart  and  great  vessels.  M.  Corvisart 
is  of  opinion  that  they  are  beneath  it.  I  have,  however,  ascer- 
tained the  incorrectness  of  this  opinion,  as  I  have  several  times 


728  PERICARDITIS. 

been  able  to  remove  the  patches,  leaving  the  serous  membrane  of 
the  pericardium  still  untouched.  Are  these  patches  the  effect 
of  partial  pericarditis,  and  the  consequent  conversion  of  the 
effused  lymph  into  a  condensed  membranous  cellular  tissue  ? 
Analogy  leads  us  to  answer  in  the  affirmative,  since  no  production 
of  this  kind  takes  place  in  the  system  without  previous  exudation 
of  coagulable  lymph.  M.  Corvisart  considers  them  as  produced 
without  previous  inflammation,  and  seated,  as  I  have  already 
said,  beneath  the  serous  surface  of  the  pericardium.  Both  these 
notions  are,  I  think,  inadmissible,  inasmuch  as  there  exists  no 
example  of  an  albuminous  exudation  on  the  adherent  surface  of 
a  serous  membrane,  and  as  facts  without  number  prove  that 
pseudo-membranous  exudations  are  almost  always  the  produce 
of  inflammation.  I  have  lately  met  with  a  case  which  appears 
to  me  to  throw  some  light  on  the  question  of  the  origin  of  these 
spots.  In  a  man  who  died  of  peripneumony,  I  found  a  thin  false 
membrane,  very  firm,  and  of  a  yellowish  color,  investing  the 
right  auricle  and  a  portion  of  the  ventricle  of  the  same  side,  all 
the  rest  of  the  pericardium  being  quite  free,  only  containing  in 
its  cavity  two  or  three  ounces  of  a  transparent  and  slightly  yellow 
serum.  Some  parts  of  the  false  membrane,  particularly  on  the 
auricle,  were  of  a  whiter  color  and  firmer  than  the  rest,  and 
exhibited  an  appearance  almost  the  same  as  the  white  patches 
above  described. 

2.  Chronic  Pericarditis. — Chronic  pericarditis  is  always  ge- 
neral, occupying  the  whole  internal  surface  of  the  serous  mem- 
brane. This  is  commonly  much  redder  than  in  the  acute  disease. 
The  redness  is  formed  by  the  close  approximation  of  minute 
points  which  look  as  if  applied  with  a  pencil.  Rarely  the 
chronic  disease  is  accompanied  by  a  pseudo-membranous  exuda- 
tion ;  and  when  this  exists,  it  is  thin,  soft,  friable  and  entirely 
resembling  a  layer  of  very  thick  pus.  In  every  case  there  exists 
a  more  or  less  copious  effusion  of  a  turbid  milky  fluid,  sometimes 
having  quite  a  puriform  character.  I  am  led  to  believe  that  the 
close  adhesion  of  the  pericardium  to  the  heart,  is  commonly  the 
consequence  of  the  absorption  of  this  fluid,  and  that  the  adhesion 
by  the  long  laminae  is  the  product  of  the  acute  disease.  In  one 
case  I  found  a  close  and  general  adhesion  of  the  pericardium  to 
the  heart  and  large  vessels,  by  means  of  a  false  fibro-cartilaginous 
membrane,  in  every  respect  like  that  of  the  pleura :  this  was, 
probably,  the  consequence  of  a  haemorrhagic  inflammation.  A 
tuberculous  eruption  may  sometimes  be  developed  in  the  false 
membrane,  and  thereby  convert  the  acute  into  the  chronic  dis- 
ease, as  frequently  happens  in  the  case  of  pleurisy  and  peritonitis. 
I  have  seen  two  cases  of  this  kind ;  and  a  third  is  noticed  in 


PERICARDITIS.  729 

Corvisart's  work  (obs.  vii.)  as  far  as  vvc  can  judge  from   the  bre- 
vity of  the  description  of  it  there  given. 

In  many  cases  of  pericarditis,  especially  in  the  chronic  disease, 
the  muscular  substance  of  the  heart  has  lost  its  color  and  be- 
come whitish,  as  if  it  had  been  macerated  for  several  days  in 
water.  This  loss  of  color  is  sometimes  attended  by  a  considera- 
ble degree  of  softening ;  and,  at  other  times,  the  consistence  is 
natural.  Most  writers  have  regarded  this  loss  of  color  as  a 
mark  of  inflammation  of  the  heart  itself,  and  most  of  the  exam- 
ples recorded  of  carditis  are  metely  cases  of  inflammation  of  the 
pericardium  accompanied  by  this  loss  of  color.  A  great  num- 
ber of  those  collected  by  M.  Corvisart  are  of  this  kind.  For  my 
own  part  I  am  disposed  to  doubt  the  correctness  of  the  opinion 
that  refers  this  loss  of  color  to  inflammation.  We  can  never 
be  sure  of  the  existence  of  inflammation  in  a  muscular  organ  un- 
less we  find  a  deposition  of  pus  among  its  fibres. 

Sect.  II. — Signs  of  Pericarditis. 

Signs  of  Acute  Pericarditis. — There  are  few  diseases  attended 
by  more  variable  symptoms  or  of  more  difficult  diagnosis,  than 
this.  Sometimes  it  appears  with  all  the  symptoms  of  a  very  vio- 
lent disease  of  the  chest,  obviously  calculated  to  carry  off  the 
patient  in  a  few  days.  At  other  times  it  proves  fatal  without 
leading  us,  in  the  least,  to  suspect  its  existence.  Again,  we  find 
cases  marked  by  all  the  symptoms  usually  attributed  by  nosolo- 
gists  to  this  disease,  and  in  the  subjects  of  which  after  death,  we 
discover  no  traces  of  its  existence.  I  have  myself  frequently 
fallen  into  both  errors,  and  I  have  seen  the  same  thing  happen 
to  the  most  skillful  practitioners.  On  the  other  hand,  I  have 
sometimes  known  these  cases  detected,  or  rather  divined,  by 
others  as  well  as  myself.  The  fact,  however,  is,  that  the  disease 
is  as  frequently  mistaken  as  recognized.  This  is  the  result  of 
my  own  experience,  up  to  the  present  time  ;  .and  to  mine  I  may 
add  that  of  many  of  my  medical  brethren,  and  among  others  M. 
Recamier. 

Corvisart  attributes  the  difficulty  of  diagnosis  •  to  the  circum- 
stance of  pericarditis  being  almost  always  complicated  with  pleu- 
risy, pneumonia,  or  some  other  disease  of  the  chest,  whieh  masks 
its  peculiar  symptoms.  These  complications,  which  are  very 
common,  must,  unquestionably  have  this  effect  where  they  exist ; 
1  must,  however,  confess,  that  the  most  completely  latent  affec- 
tions of  this  kind  that  I  have  met  with,  were  in  subjects  whose 
thoracic  viscera  were,  in  other  respects,  quite  sound,  and  who  had 
died  of  disease  of  the  abdomen.  These  facts  seem  to  prove  that 
inflammation  of  the  pericardium  is  sometimes  a  local  affection  of 
92 


730  PERICARDITIS. 

little  violence,  and  of  very  inconsiderable  influence  on  the  general 
system,  or  even  on  the  circulation  ;  while,  in  other  cases,  it  is 
accompanied  by  an  acute  fever,  and  by  such  violent  disorder  of 
almost  all  the  functions,  as  to  compromise  the  life  of  the  patient. 
M.  Corvisart,  is  likewise  of  opinion,  that  it  is  when  the  disease  is 
very  acute,  that  the  symptoms  are  very  obscure.  Its  invasion, 
he  says,  is  then  sudden,  its  progress  rapid,  its  termination  almost 
instantaneous.  When  it  exists  in  a  less  violent  degree,  but  still 
acute,  he  thinks  it  can  be  recognized  by  the  following  symptoms : 
viz.  sense  of  heat  in  the  region «of  the  heart;  great  difficulty  of 
respiration ;  greater  color  of  the  left  cheek  than  the  right ; 
pulse,  at  first,  frequent,  hard,  and  rarely  irregular,  becoming, 
about  the  third  or  fourth  day,  small,  hard,  contracted,  and  often 
irregular ;  great  anxiety,  slight  palpitations ;  partial  faintings  ; 
peculiar  change  of  features ;  and  (towards  the  fatal  close  of  the 
disease)  total  or  partial  cessation  of  the  local  pain  ;  intermitting, 
very  irregular,  almost  imperceptible  pulse ;  fits  of  suffocation, 
insupportable  anxiety,  and  general  anasarca. 

These  symptoms  are,  certainly,  sometimes  present  in  pericar- 
ditis ;  but  each,  or  all  of  them,  may  be  absent,  and  some  of  them 
are  very  rare.  I  have  never  observed  the  increased  color  of  the 
cheek,  have  rarely  heard  complaints  of  local  heat  or  pain  ;  and, 
in  place  of  the  progressive  increase  of  irregularity  in  the  pulse, 
(as  described  by  M.  Corvisart,)  I  have  uniformly  found  this  ir- 
regularity intermitting,  wiry,  and  almost  imperceptible,  from  the 
very  commencement  of  the  disease. 

I  must  admit  that  the  stethoscope  scarcely  furnishes  us  with 
any  more  certain  signs  of  this  disease.  The  following  appear  to 
me  to  be  the  most  common  symptoms  of  the  inflammation  of  the 
pericardium,  when  not  latent :  the  contraction  of  the  ventricles 
yields  a  greater  shock,  and  sometimes  a  more  marked  sound  than 
usual,  and,  at  intervals,  feebler  and  shorter  pulsations  are  per- 
ceived, which  correspond  with  intermissions  of  the  pulse,  the 
smallness  of  which  contrasts  remarkably  with  the  strength  of  the 
heart's  pulsation  :  sometimes  the  pulse  can  scarcely  be  felt  at  all. 
When  these  symptoms  come  on  suddenly  in  a  person  who  had 
never  been  affected  with  disease  of  the  heart,  there  is  great  pro- 
bability of  their  being  the  consequence  of  this  disease.  It  is  fur- 
ther common  for  the  patient  to  have  more  or  less  dyspnoea,  great 
distress  in  the  cardiac  region,  and  extreme  anxiety  ;  and  to  suffer 
syncope  on  taking  a  few  steps,  or  on  moving  suddenly  in  his  bed. 
The  feeling  of  pain,  heat  or  weight  in  the  region  of  the  heart, 
is  a  much  rarer  symptom,  yet  it  is  sometimes  met  with.  In 
some  cases,  the  cardiac  region  yields  the  dead  sound  ;  but  most 
frequently  this  sign  is  far  from  being  distinct.  I  must  repeat, 
however,  that  we  must  not  accord  too  implicit  confidence  to  these 


PERICARDITIS. 


731 


signs,  even  when  they  co-exist ;  for  pericarditis  may  assuredly 
exist  without  them,  and  they  without  pericarditis.  The  accumu- 
lation of  blood  in  the  heart,  and  the  polypous  concretions,  the  con- 
sequence of  this,  give  rise  to  precisely  the  same  symptoms.* 

*  Lacnnec  has  here  taken  no  notice  of  the  leather-creak  which  he  had  at  one 
time  regarded  as  a  probable  sign  of  pericarditis,  (see  p.  610.)  I  am  neverthe- 
less, still  of  opinion  that  this  phenomenon  ought  to  be  observed  in  every  case 
of  this  disease,  at  least  at  one  particular  period  of  its  progress.  Two  old  pupils 
of  the  Necker  Hospital,  M.  M.  Collin  and  Devellier,  are  positive  in  haviug 
proved  the  existence  of  this  sign  in  two  cases, — the  former,  in  a  man  who  died 
of  chronic  pericarditis,  and  in  whom  the  pulsations  of  the  heart  were  accompa- 
nied for  six  days  with  this  leather-creak,  and' which  only  ceased  when  the  local 
symptoms  indicated  the  supervention  of  a  copious  effusion  into  the  pericardium  ; 
— the  latter,  in  a  man  who  also  died  of  chronic  pericarditis,  and  in  whom  the 
sound  was  present  during  the  whole  period  of  his  stay  in  the  hospital :  on  ex- 
amination after  death  there  was  found  no  liquid  effusion  in  the  pericardium,  but 
the  whole  surface  of  the  sac  was  covered  with  thick  false  membranes,  like 
vegetations.  M.  Collin,  who  has,  I  know  not  wherefore,  assumed  the  honor  of 
having  first  observed  the  leather-creak,  considers  it  to  be  produced  by  that  par- 
ticular dryness  which  the  pericardium,  in  common  with  all  other  serous  mem- 
branes, presents  at  the  commencement  of  inflammation,  and  ingeniously  assimi- 
lates it  with  the  sound  produced  by  the  friction  of  the  patella  on  the  condyles  of 
the  knee  bones,  in  cases  of  chronic  rheumatism  without  effusion.  (Diverscs 
Methodes  a" exploration,  $-c.  Par.  1823.)  We  have  had  already  occasion  to  con- 
sider (see  chap.  on.  Pleurisy)  the  value  of  this  pretended  dryness  of  serous 
membranes  in  a  state  of  inflammation  ;  and  we  cannot,  therefore,  regard  M. 
Collin's  explanation  as  further  admissible  than  that  the  sound  is  clearly  the  re- 
sult of  friction.  It  is  indeed  a  parallel  case  to  the  sound  of  friction  observed  in 
pleurisy,  and  from  the  two  cases  above  quoted,  it  is  evident  that  it  depends,  like 
that,  on  the  presence  of  a  pseudo-membranous  exudation  of  unequal  thickness, 
or,  in  other  words,  on  the  absence  of  the  natural  smoothness  of  the  membrane. 
— (M.  L.) 

Since  the  publication  of  the  present  edition  of  our  author's  treatise,  the  pro- 
fession in  this  country  have  been  supplied,  by  a  distinguished  auscultator  and 
pathologist,  Dr.  Stokes  of  Dublin,  witli  two  most  valuable  and  interesting  me- 
moirs on  the  subject  of  pericarditis,  {Dublin  Journ.  March  and  Sept.  1833,)  from 
which  it  results  that  the  original  opinion  of  Laennec,  and  the  actual  belief  of 
his  cousin  and  of  M.  Collin,  respecting  the  value  of  the  leather-creak  from  fric- 
tion of  the  pericardium,  as  a  sign  of  this  disease,  is  irrefragably  confirmed. 
The  important  fact  discovered  by  Dr.  Stokes,  of  the  occasional  great  similarity 
of  this  sound  to  that  of  the  common  bellows-sound  from  affection  of  the  valves, 
reconciles  his  conclusions,  in  a  most  satisfactory  manner,  with  the  preceding  re- 
marks of  Dr.  Hope,  Dr.  Latham,  and  my  own.  Dr.  Williams,  a  great  authority, 
informs  me  that  his  recent  experience  leads  him  likewise  to  admit  the  value 
of  this  sign  in  pericarditis.  The  following  propositions  are  given  by  Dr.  Stokes, 
as  containing  the  general  results  of  his  researches  :  for  more  complete  informa- 
tion I  refer  the  reader  to  the  original  memoirs  : — "  1.  That,  in  cases  of  pericar- 
ditis with  effusion  of  lymph,  the  rubbing  of  the  two  roughened  surfaces  causes 
sounds  perceptible  to  the  ear,  and  vibrations  communicable  to  the  hand,  by  which 
the  disease  can  be  easily  and  securely  recognized,  even  when  all  other  symp- 
toms are  absent.  2.  That  the  more  rough  is  the  state  of  the  serous  membrane, 
the  more  distinct  will  these  signs  be.  3.  That  the  sounds  accompany  the  two 
sounds  of  the  heart  in  almost  all  cases.  4.  That  they  are  audible  generally 
only  over  the  region  of  the  heart.  5.  That  they  present  themselves  with 
various  modifications  of  character,  but  often  resemble  the  sounds  produced 
by  extensive  valvular  disease.  6.  That  they  are  more  distinct  when  the  region 
of  the  heart  continues  with  its  natural  sound  on  percussion,  but  that  the  exist- 
ence of  fluid  does  not  necessarily  imply  their  complete  subsidence.  7.  That 
they  may  re-appear  after  the  absorption  of  fluid  from  the  bag  of  the  pericar- 
dium, or  the  new  supervention  of  inflammation.  8.  That  the  sounds  may  con- 
tinue  when  the  sensation   of  rubbing  is   no   longer  perceptible   by  the   hand. 


732  PERICARDITIS. 

Before  the  conversion  of  false  membranes  into  cellular  tissue 
was  well  understood,  the  adhesion  of  the  pericardium  to  the  heart 
was  regarded  by  divers  authors  as  a  cause  of  various  and  serious 
complaints.  Lancisi  and  Vieussens  considered  it  as  constantly 
causing  palpitation  ;  Meckel,  as  rendering  the  pulse  habitually 
small ;  and  Senac,  as  productive  of  frequent  faintings.  Even  M. 
Corvisart  himself  lias  fallen  into  some  mistakes  on  this  head. 
He  admits  three  species  of  adhesions, — all  of  which  I  have  just 
described  as  mere  varieties  or  stages  of  the  same  affection.  These 
are,  1st,  a  demi-concrete  albuminous  adhesion,  which  is  the  only 
one  recognized  by  him  as  the  consequence  of  pericarditis  ;  2nd, 
the  very  intimate  or  close  cellular  adhesion,  deemed  an  effect  of 
gouty  or  rheumatic  affections ;  and  3rd,  the  extended  or  long  cel- 
lular adhesion,  the  cause  of  which  is  not  assigned  by  him.  M. 
Gorvisart  is  further  of  opinion,  that  no  person  can  live,  and  pre- 
serve a  good  state  of  health,  who  is  affected  with  a  complete 
and  close  adhesion  of  the  pericardium  to  the  heart,  or  of  the 
lungs  to  the  pleura.  I  have,  however,  met  with  many  cases 
where  this  condition  of  parts  was  found  after  death,  in  which  no 
disorder  of  the  respiration  or  circulation  existed  during  life.  It 
has  only  appeared  to  me  that  the  contraction  of  the  auricles  has 
become  much  duller  when  they  are  adherent  to  the  pericardium. 
A  case  adduced  by  M.  Corvisart  in  support  of  his  opinion  (Op. 
Cit.  p.  34)  appears  to  me  rather  conclusive  against  it,  inasmuch 
as  the  appearances  on  dissection  showed  sufficient  lesions  in  other 
organs  to  account  for  the  symptoms  referred  by  him  to  the  adhe- 
sions between  the  heart  and  pericardium. 

I  have  understood  that  an  English  physician,  Dr.  Sanders,  has 
announced  as  an  infallible  sign  of  the  adhesion  of  the  pericardium 
to  the  heart,  the  existence  of  a  hollow, »during  each  systole  of  the 
organ,  in  the  epigastrium,  immediately  below  the  left  false  ribs. 
Kreysig  attributes  the  same  remark  (vol.  ii.  p.  623)  to  Dr.  Heim 
of  Berlin.  During  the  last  two  years,  I  have  sought  in  vain  to 
verify  this  observation  among  all  my  patients  who  presented  any 
disorder  of  the  circulation  ;  and  in  none  of  them  have  I  found  the 

9.  That  they  are  singularly  and  rapidly  modified  by  direct  antiphlogistic  treat- 
ment to  the  heart.  10.  That  by  observing  the  progress  and  mutations  of  those 
signs,  we  can  trace  the  progress  of  organization  or  obliteration  of  the  pericardial 
cavity,  judge  of  the  effect  of  treatment,  and  accurately  ascertain  the  exact  state 
of  the  pericardium.  11.  That,  hence,  it  must  be  admitted  that  auscultation  is  of 
direct  utility  in  pericarditis,  and  that  the  diagnosis  no  longer  rests  on  negative 
signs." — Dub.  Journ.  vol.  iv-  p.  60.  The  facts  so  concisely  announced  in  the 
preceding  propositions  are  of  such  practical  importance,  that  I  must  recommend 
the  attentive  consideration  of  every  one  of  them  to  the  reader.  It  is  most  grati- 
fying to  those  who  were  the  early,  and  by  some  the  suspected  advocates  of 
auscultation,  to  find  it  gradually  working  its  way  to  the  high  places  of  the  profes- 
sion, and  vindicating  its  true  philosophical  character  and  practical  value  by  suc- 
cessive improvements  and  discoveries,  among  the  most  valuable  of  which  I  do 
not  hesitate  to  regard  those  of  Dr.  Stokes  detailed  in  the  present  note.—  Trans! . 


PERICARDITIS. 


783 


epigastric  depression,  although  several  had  this  very  adhesion  of 
the  pericardium. 

The  signs  of  chronic  pericarditis  are  still  more  uncertain  than 
those  of  the  acute  disease.  This  uncertainty  arrises  not  merely 
from  the  variability  of  the  signs,  but  also  from  the  greater  rarity 
of  the  disease  in  an  essentially  chronic  state.  I  have  attended 
several  cases  which  I  considered,  throughout  their  whole  course, 
as  chronic  inflammations  of  the  pericardium,  but  which  were 
almost  all  cured.  In  two  or  three  cases  only,  have  I  been  able  to 
verify  the  correctness  of  my  diagnosis  by  examination  after  death  ; 
whilst  frequently  I  have  found  the  pericardium  full  of  pus,  and 
in  a  true  state  of  chronic  inflammation,  without  having  been  at 
all  led  to  suspect  such  an  affection.  In  the  cases  which  have  oc- 
curred within  the  last  few  years,  I  have  found  the  symptoms  to 
be  precisely  the  same  as  in  the  acute  disease,  only  less  violent. 
Percussion  alone  may  afford  some  assistance,  but  only  in  the  case 
where  effusion  is  considerable.  From  one  to  two  years  has 
elapsed  before  a  cure  has  taken  place.  This  has  been  almost  in- 
sensible in  its  progress ;  and  when  it  has  been  effected,  the  action 
of  the  heart  and  pulse  has  become  natural  and  regular.* 

*  Inflammation  of  the  pericardium  is  of  much  more  frequent  occurrence,  both 
in  the  acute  and  chronic  form,  than  is  generally  supposed.  It  is  no  wonder  that 
it  is  so  constantly  mistaken  or  overlooked  by  common  practitioners,  after  the 
confession  of  inability  to  detect  it,  made  by  our  author  in  the  text.  It  is  of 
great  importance,  however,  that  it  should  be  distinguished  ;  and  it  need  hardly 
be  said,  after  the  statements  made  in  the  last  note,  that  its  diagnosis  is  now  in 
a  very  different  state  from  that  in  which  our  author  left  it.  Dr.  Stokes'  observa- 
tions apply  chiefly  to  the  dry  pericarditis  ;  and  M.  Louis's  memoir,  which  ap- 
plies more  particularly  to  that  with  copious  liquid  effusion,  leaves  little  to  be 
desired  as  to  its  verification.  This  distinguished  pathologist  is  of  opinion  that 
the  dull  sound  on  percussion,  when  percussion  is  properly  conducted  and  due 
regard  is  had  to  the  history  of  the  case,  may  alone  be  considered  as  almost  an 
infallible  sign  of  the  disease.  Our  documents  respecting  the  history  of  this  dis- 
ease are  now  very  ample ;  and  I  earnestly  recommend  the  careful  study  of  them 
to  the  young  practitioner.  Want  of  space,  from  the  already  too  great  size  of 
this  volume,  prevents  me  from  doing  more  in  this  place  than  indicating  some  of 
the  best  sources  of  information,  and  a  good  deal  that  is  not  noticed  by  M.  Laen- 
nec.  The  different  varieties  of  this  affection  are  treated  of  by  Testa  in  several 
chapters,  and  also  by  Kreysig  in  different  parts  of  his  elaborately  misarranged 
book.  The  most  recent  and  best  accounts  are  those  by  Bertin,  (Malad.  du  Cceur, 
p.  29,)  Andral,  (Clin.  Med.  t.  iii.  p.  415,)  Louis,  (Memoiris  on  Recherches,  p. 
253,)  Hope,  (Dis.  of  the  Heart,  p.  84,  and  Cyc.  of  Pract.  Med.  vol.  iv.,)  Latham, 
(Med.  Gazette,  vol.  iii.  p.  213,)  Stokes,  (Dub.  Journ.  vol.  Iii.  p.  63;  vol.  iv.  p. 
29.)  For  the  Literature  of  Pericarditis,  see  end  of  chap,  on  Carditis.  A  vast 
number  of  separate  cases  of  this  affection  are  scattered  through  the  works  ot 
practical  writers,  and  the  periodical  literature  of  this  and  foreign  countries. 
Several  are  contained  in  my  work  on  the  Stethoscope. 

The  treatment  of  pericarditis  has  been  entirely  overlooked  by  our  author, — 
an  important  subject,  which  I  can  merely  allude  to  in  this  place.  The  general 
principle  of  treatment  must  be  the  same  as  that  of  pleurisy,  only  that  the  deple- 
tory measures  ought  to  be  still  more  active  in  pericarditis,  as  well  on  account 
of  the  more  important  character  of  the  part  affected,  as  because  the  omission  of 
them  will  be  productive  of  greater  local  mischief  than  in  the  case  of  pleurisy. 
Two  modes  of  restoration  are  possible ;  the  one  complete,  by  the  resolution  of 


734  HYDRO-PERICARDIUM. 


CHAPTER  XXIII. 


OF    HYDRO-PERICARDIUM. 

It  is  extremely  common  to  find  a  greater  or  less  quantity  of 
serum  in  the  pericardium ;  most  frequently  this  does  not  exceed 
a  few  ounces,  and  can  rarely  be  considered  as  idiopathic  in  its 
origin.  Most  commonly  it  can  only  be  regarded  as  taking  place 
in  articulo  mortis,  or  immediately  after  death.  When  there 
exists  a  general  dropsical  diathesis,  we  occasionally  find  some 
water  in  the  pericardium ;  but,  in  general,  it  contains  less  than 
the  other  serous  cavities.  In  the  idiopathic  hydro-pericardium, 
on  the  contrary,  the  pericardium  is  commonly  the  only  membrane 
which  contains  serous  effusion.  The  effused  serum  is  sometimes 
colorless,  but  more  commonly  it  is  yellowish,  brownish,  or  reddish, 
although  still  perfectly  limpid,  and  without  any  admixture  of  flakes 

the  inflammation  and  the  absorption  of  the  whole  of  the  effused  fluid;  the  other 
incomplete,  by  the  resolution  of  the  inflammation,  the  absorption  of  the  serous 
portion  of  the  effusion,  and  the  more  or  less  extensive  agglutination  of  the  loose 
to  the  adherent  pericardium,  by  means  of  the  extravasated  lymph  :  if  neither  of 
these  terminations  ensues,  but  the  pericardium  remains  distended  with  fluid, 
death  may  be  said  to  be  almost  inevitable.  Hence  the  extreme  importance  of 
prompt  and  active  measures  in  the  very  commencement  of  this  disease,  by  which, 
if  we  fail  in  producing  the  first  and  most  desirable  result,  we  may  entertain  a 
confident  hope  of  effecting  the  second  ;  for  although  adhesion  of  the  pericardi- 
um to  the  heart,  especially  if  of  considerable  extent,  is  a  serious  evil  and  almost 
always  productive  of  yet  greater  organic  disease  of  the  organ,  and  eventually 
of  death,  still  it  is  a  great  object  to  attain  even  this  termination,  in  the  severer 
cases.  Immediately  after  the  employment  of  copious  venesection  and  cupping 
or  leeching,  or  rather  contemporaneously  jvith  the  latter,  the  system  should  be 
brought  under  the  influence  of  mercury  as  speedily  as  possible  by  the  free  ad- 
ministration of  calomel,  or  of  calomel  and  opium  on  the  plan  of  Dr.  Hamilton. 
This  plan  of  treatment  originally  introduced  by  Dr.  Farre  has  been  more  recent- 
ly advocated  by  Dr.  P.  M.  Latham,  (see  his  excellent  essays  on  diseases  of  the 
heart  in  the  third  volume  of  the  Med.  Gazette,)  and  enforced  by  the  evidence 
of  numerous  facts  and  by  the  most  conclusive  reasoning.  "  From  acute  peri- 
carditis which  has  proceeded  to  the  deposition  of  lymph,  nothing,  I  believe 
(says  Dr.  L.)  can  ensure  a  perfect  recovery  but  mercury  so  employed  as  to  pro- 
duce its  peculiar  and  specific  influence  upon  the  constitution, — mercury  pro- 
ducing salivation.  I  would  not  hazard  this  assertion  unless  I  firmly  believed 
that  the  fact  was  brought  as  near  to  demonstration  as  the  nature  of  things  al- 
lows." p.  215.  Dr'.  Latham  is  convinced  that  mercury  has  the  power  of  even 
arresting  the  deposition  of  lymph  as  well  as  of  promoting  its  absorption,  in  acute 
inflammations  in  general,  a  fact,  indeed,  visibly  proved  in  cases  of  iritis  not  of  a 
syphilitic  nature  ;  and  as  he  maintains  that  "  after  an  inflammation  of  the  peri- 
cardium has  absolutely  ceased,  and  the  patient's  life  is  saved  for  the  present,  if 
adhesion  remain,  death  will  nevertheless  be  the  consequence  in  the  end,"  the 
paramount  importance  of  this  mode  of  treatment  cannot  be  placed  in  a  stronger 
light.  I  will  only  further  add,  that,  as  it  is  only  in  the  acute  stage  of  the  disease, 
that  much  benefit  can  be  expected  from  this  or  any  other  measure,  no  means 
ought  to  be  neglected  of  establishing  a  correct  diagnosis, — the  only  basis  on 
which  successful  practice,  in  this  or  any  other  disease,  can  be  established.— 
Transl. 


HYDRO-PERICARDIUM. 


735 


of  lymph ; — rarely  it  is  sanguineous.  It  is  variable  in  amount, 
Most  frequently  it  does  not  exceed  one  or  two  pounds,  but  it  has 
been  found  in  much  greater  quantity  than  this.  M.  Corvisart 
(Op.  Cit.  p.  53.)  records  an  instance  wherein  eight  pounds  were 
found.  This  effusion  is  attended  by  no  change  in  the  heart,  or 
its  coverings.  Some  authors  have,  indeed,  stated  the  heart  to 
have  appeared  as  if  macerated  in  such  cases ;  but  I  am  disposed 
to  consider  such  statements  as  the  result  of  imperfect  observation 
and  incorrect  description. 

Signs. — Authors  vary  respecting  the  symptoms  of  this  affec- 
tion. Lancisi  states  the  principal  to  be,  a  sensation  of  an  enor- 
mous weight  in  the  region  of  the  heart.  Reimann  and  Saxonia 
assure  us,  that  the  patient  feels  his  heart  swimming  in  water. 
Senac  says,  he  has  seen  the  fluctuation  of  the  fluid  between  the 
third,  fourth,  and  fifth  ribs.  M.  Corvisart  says,  he  has  perceived 
this  fluctuation  by  the  touch,  and  adds  the  following  marks  of 
the  affection  : — sense  of  weight  in  the  region  of  the  heart ;  di- 
minished resonance  on  percussion  ;  pulsation  of  the  heart  irre- 
gular and  obscure,  and  felt  over  a  large  space,  and  with  variable 
intensity,  in  the  same  and  different  points  of  this  space ;  pulse 
small,  frequent,  and  irregular ;  threatened  suffocation  on  lying 
in  the  horizontal  posture  ;  frequent  syncope,  but  rarely  palpita- 
tion ;  oedema.  To  these  symptoms  I  may  apply  the  same  re- 
marks as  to  those  of  pericarditis ;  they  may  exist,  in  greater  or 
less  number,  and  with  or  without  hydro-pericardium.  The  ste- 
thoscope will,  no  doubt,  assist  us  in  the  diagnosis  ;  but  from 
having  had  few  opportunities  of  witnessing  the  idiopathic  affec- 
tion, I  am  unable  to  say  what  precise  signs  it  will  supply.  When 
the  effusion  is  in  small  quantity,  (less  than  a  pint,  for  instance,) 
I  am  of  opinion  that  it  will  be  indicated  by  no  certain  sign,  but 
that  when  it  exceeds  two'  or  three  pints,  it  may  sometimes  be  re- 
cognized by  means  of  percussion,  auscultation,  and  inspection  of 
the  chest.* 

In  this  case  a  precise  diagnosis  is  the  less  to  be  regretted, 
firstly,  because  the  disease  is  so  extremely  rare  ;  and,  secondly, 
because  it  is  so  little  under  the  control  of  medicine.  It  may, 
however,  be  possibly  removed  by  a  surgical  operation.  And, 
were  this  to  be  had  recourse  to,  I  would  not  recommend  a  punc- 
ture between  the  cartilages  of  the  ribs,  as  advised  by  Senac  and 
practised  by  Desault;  but  that  the  sternum  should  be  trepanned. 
This  operation  is  not,  in  itself,  at  all  dangerous,  and  is  of  easy 
performance.  By  means  of  it  we  are  enabled  to  see  and  touch 
the  pericardium ;  and  may  thus  verify  our  diagnosis,  before  pro- 

*  The  experience  of  Louis,  given  in  the  last  chapter  on  pericarditis,  proves 
our  author  to  be  under  a  mistake  as  to  the  maximum  quantity  of  fluid  that  can 
be  detected,  by  means  of  percussion,  in  the  pericardium.—  Transl. 


736  PNEUMOPERICARDIUM. 

ceeding  to  lay  open  the  membrane.  This  is  the  only  part  of  the 
operation  attended  with  danger,  from  inflammation  produced  by 
the  admission  of  air ;  and  yet  it  might  be,  perhaps,  advisable  to 
excite  this  very  state  by  means  of  slightly  stimulant  injections,  in 
order  to  effect  a  cure  of  the  disease.* 


CHAPTER  XXIV. 


OF    PNEUMOPERICARDIUM. 


By  this  expression  I  shall  designate  those  collections  of  air,  how- 
soever produced,  which  are  met  with  in  the  pericardium.  They 
are  very  often  observed  in  the  examination  of  dead  bodies,  par- 
ticularly such  as  have  been  kept  some  time.  In  the  latter  case, 
the  effusion  is,  no  doubt,  the  effect  of  decomposition,  but  in  many 
others  the  complete  absence  of  all  signs  of  putrescence  proves  it 
to  have  existed  previously  to  death.  Sometimes  the  air  is  com- 
bined with  a  liquid,  and  this  is  by  much  the  most  frequent  case  ; 
at  other  times  the  pericardium  is  distended  by  air  alone.  The 
effusion  of  air  and  serum  into  the  pericardium,  may  occur  in  the 
agony  of  all  diseases.  I  have  sometimes  been  enabled  to  announce 
its  presence,  from  the  supervention  of  an  increased  resonance  over 
the  lower  part  of  the  sternum,  and  from  the  existence  of  the  sound 
of  fluctuation  produced  by  the  action  of  the  heart,  and  by  deep 
inspirations.! 

As  these  observations  were  anterior  to  those  made  respecting 
the  sound  of  the  heart's  action  heard  at  a  distance  from  the  body, 
(See  Sect.  III.  Chap.  V.  of  the  present  book,)  I  did  not  ascertain 
whether  this  last-mentioned  phenomenon  was  present  or  not :  but 
I  am  convinced  that  in  almost  all  the  cases  where  the  sound  is 
heard  at  a  distance,  the  cause  of  the  phenomenon  is  a  temporary 
development  of  gas  in  the  pericardium :  this  gas  being,  most  fre- 

*  For  some  curious  cases  of  this  affection,  in  which  lapping  was  successfully 
performed  by  Dr.  Romero,  a  Spanish  physician,  the  reader  is  referred  to  Dr. 
Johnson's  Review  for  Dec.  1820,  p.  477.—  Transl. 

t  I  lately  saw  a  woman  who  complained  of  palpitations  of  the  heart.  Each 
stroke  of  this  organ  was  accompanied  by  a  peculiar  gurgling  sound,  which 
evidently  came  from  the  precordial  region,  and  was  heard  only  when  the  heart 
struck  the  ribs  :  it  was  perceptible  at  a  distance.  I  thought  this  a  ease  of  hydro- 
pneumo-pericardium . 

Dr.  Bricheteau  has  quoted  a  case  where  a  sound  issued  from  the  precordial 
regions  like  that  of  a  water-wheel :  it  was  heard  only  during  each  pulsation  of 
the  heart.  On  opening  the  body,  the  pericardium  was  found  filled  with  a  fetid 
purulent  liquid.  When  the  pericardium  was  cut,  a  quantity  of  gas  escaped  with 
a  hissing  noise.  Before  incision,  the  pericardium,  on  percussion,  yielded  a 
bruit  deflot,  or  wave-like  sound. — jJndral 


ACCIDENTAL    PRODUCTIONS    IN    THE    PERICARDIUM.  737 

quently,  speedily  re-absorbed,  and  while  present  occasioning  no 
serious  inconvenience.  A  physical  phenomenon  of  this  kind 
must  acknowledge  a  cause  analogous  to  those  which  produce 
similar  effects  ;  and  in  reference  to  this  particular  phenomenon, 
I  can  conceive  only  four  capable  of  giving  rise  to  it :  1 .  that  just 
mentioned ;  2.  the  development  of  gas  in  the  cavities  of  the  heart 
themselves — a  proposition  altogether  inadmissible,  since  death 
must  instantly  be  the  consequence  of  such  a  state  ;  3.  the  ossifi- 
cation of  a  portion  of  the  heart's  surface  corresponding  to  the 
sternum  or  cartilages  of  the  ribs — a  condition  of  parts  incom- 
parably more  rare  than  the  phenomenon  in  question ;  lastly,  the 
co-existence  of  such  a  degree  of  induration  of  the  muscular  sub- 
stance of  the  heart  with  such  violent  action  of  it,  as  to  render  its 
impulse  against  the  thoracic  parietes  (that  is,  the  contact  of  two 
surfaces  comparatively  soft  and  moist)  productive  of  a  sufficient 
degree  of  resonance.  This  last  hypothesis  becomes  the  more 
improbable  from  this  consideration,  that  when  the  heart  is  in- 
durated it  is  also  hypertrophied ;  and  we  know  that  the  persons 
in  whom  the  sound  of  the  heart  is  heard  at  a  distance,  are  almost 
always  nervous  subjects,  with  a  soft  muscular  fibre,  and  a  heart 
possessing  very  little  real  force  of  contraction. 


CHAPTER  XXV. 

OF    ACCIDENTAL    PRODUCTIONS    IN    THE    PERICARDIUM. 

Various  species  of  accidental  productions  have  been  found  be- 
tween the  pericardium  properly  so  called,  and  the  pleura  ;  also, 
between  it  and  the  internal  and  serous  membrane ;  and,  lastly, 
between  the  serous  membrane  and  the  heart.  In  the  Sepulchretum 
of  Bonetus,  and  other  collections  of  cases,  we  find  examples  of 
what  appear  to  be  tubercles,  cancerous  tumors,  or  cysts,  in  the 
different  situations  just  mentioned.  But  the  imperfect  knowledge 
of  membranes  before  the  time  of  Bichat,  and  the  general  con- 
fusion of  all  accidental  productions  under  the  names  of  scirrhus, 
carcinoma,  atheroma,  &c.  renders  it  impossible  to  ascertain  pre- 
cisely either  the  nature  or  site  of  such  morbid  growths.  I  have 
already  noticed  the  fatty  productions,  in  the  form  of  a  cock's 
comb,  developed  occasionally  between  the  pleura  and  fibrous 
membrane  of  the  pericardium.  Twice  or  thrice  I  have  found 
tubercles  in  the  same  situation,  in  subjects  which  exhibited  a 
great  number  of  these  bodies  in  the  lungs  and  elsewhere.  I  have 
also  seen  a  tubercle  situated  at  the  point  of  the  origin  of  the  pul- 
93 


738  ACCIDENTAL    PRODUCTIONS    IN    THE    PERICARDIUM 

monary  artery  and  beneath  the  serous  membrane  of  the  pericar- 
dium. 

Once  only  have  I  met  with  an  instance  of  ossification  between 
the  layers  of  the  pericardium.  As  this  case  was  remarkable  both 
for  its  extent  and  the  effects  produced  by  it,  I  shall  here  briefly 
detail  it. 

Case  XLVI. — A  man  aged  sixty-five  years,  had  led  an  intem- 
perate life,  but  had,  nevertheless,  enjoyed  good  health  until  his 
fiftieth  year.  At  this  time  he  appears  to  have  had  an  attack  of 
pleurisy  of  short  duration,  but  which  was  followed  by  cedema 
of  the  lower  extremities,  and  subsequently  by  anasarca  of  other 
parts,  and  by  dyspnoea  and  breathlessness  on  ascending  a  height, 
or  using  any  degree  of  exercise.  When  he  came  into  the  hos- 
pital, in  the  end  of  spring,  the  dropsical  symptoms  continued 
and  the  lips  were  swollen  and  blue.  The  pulsations  of  the  heart 
were  unequal,  irregular,  and  very  distinct,  though  perceptible  over 
a  very  small  extent  of  the  chest.  The  pulse  was  feeble,  small, 
soft,  unequal,  intermittent,  and  irregular.  There  was  no  cough, 
but  copious  expectoration.  The  thorax  sounded  well  superiorly, 
but  badly  on  the  lower  parts.  The  patient  could  lie  in  any  pos- 
ture ;  slept  well,  even  without  having  his  head  raised,  and  had  no 
sudden  startings  from  sleep.  He  died  in  the  course  of  a  few 
months,  the  dropsical  swellings  and  dyspnoea  having  much  increa- 
sed. 

Dissection  twenty-four  hours  after  death. — The  brain,  lungs, 
and  abdominal  viscera  were  found  in  a  sound  state.  The  heart 
was  enlarged,  and  adhered  throughout  to  the  pericardium,  by 
means  of  very  close  cellular  attachments.  On  first  touching  it, 
it  seemed  to  be  quite  enclosed  in  a  bony  case,  situated  beneath 
the  fibrous  membrane  of  the  pericardium ;  but  on  further  exa- 
mination this  incrustation  was  found  to  be  incomplete.  Around 
the  base  of  the  ventricles  there  was  a  zone  or  band,  partly  bony 
and  partly  cartilaginous,  of  from  one  or  two  fingers'  breadth,  of 
unequal  thickness,  flattened,  yet  somewhat  rough  on  its  surface. 
This  band  projected  into  the  angle  between  the  ventricles  and 
auricles,  and  extended  along  the  interventricular  septum  on  both 
sides,  to  near  the  apex  of  the  heart.  The  whole  of  this  produc- 
tion was  containedj  between  the  fibrous  membrane  of  the  pericar- 
dium and  the  serous  membrane  which  lines  it  internally.  The 
auricles  were  enlarged  so  that  each  might  have  contained  a  large 
egg.  One  of  the  mitral  valves  contained  an  ossified  point  of  the 
size  and  shape  of  a  French  bean. 

In  1823  I  met  with  a  similar  case,  only  that  the  incrustation 
was  less  extensive.  Cruwell,  Pasta,  and  Burns,  seem  to  have  ob- 
served analogous  instances.* 

*  See  also  Baillie's  Morb.  Anat.  p.  Vd.—  Transl. 


DISEASES    OF    THE    VESSELS. 


739 


CHAPTER  XXVI. 

OF  ORGANIC  AFFECTIONS  OF  THE  VESSELS  OF  THE  HEART. 

The  Coronary  Vessels. — The  most  common  disease  of  the  co- 
ronary arteries  is  ossification.  It  presents  precisely  the  same 
characters  as  the  same  morbid  condition  in  other  vessels.  Bertin 
(p.  514)  has  found  one  of  the  arteries  entirely  obliterated  from 
this  cause.  In  the  case  of  simple  dilatation  of  the  heart,  or  of 
dilatation  with  hypertrophy,  we  very  frequently  find  the  coronary 
arteries  dilated  through  their  whole  extent.  In  an  example  of 
hypertrophy  of  the  left  ventricle,  Bertin  found  the  left  coronary 
artery  of  double  the  diameter  of  the  right.  The  only  morbid 
change  of  the  coronary  veins  that  I  have  met  with  is  their  gene- 
ral dilatation.  In  rare  instances  they  present,  like  the  varicose 
veins  of  the  extremities,  some  points  much  more  distended  than 
others.  The  circumstance  that  strikes  us  most,  at  first  sight,  in 
this  case,  is  the  prolongation  of  the  natural  flexions  of  the  ves- 
sels, their  length  as  well  as  diameter  being  increased.  This  ap- 
pearance is  particularly  observable  in  subjects  who  have  long 
labored  under  dilatation  or  hypertrophy  of  the  heart.  The  ossi- 
fication of  the  coronary  arteries  has  been  regarded  by  Heberden 
and  Parry  as  the  cause  of  angina  pectoris ;  and  this  opinion  has 
been  adopted  by  almost  all  the  English  and  German  physicians : 
I  shall  investigate  its  correctness  when  treating  of  the  disease  in 
question. 

The  Pulmonary  Artery. — The  affections  of  the  pulmonary 
artery  are  few  in  number.  Those  which  have  been  hitherto  ob- 
served are  only  the  dilatation  and  bony  incrustation  of  this  vessel. 
Of  this  latter  affection  there  are  not  more  than  three  or  four  cases 
on. record,  if  we  except  those  in  which  there  existed  a  preterna- 
tural communication  between  the  right  and  left  cavities  of  the 
heart.*  It  is  by  no  means  very  rare  to  find  the  pulmonary  artery 
dilated  beyond  the  usual  size.  I  have  found  its  diameter  greater 
than  that  of  the  aorta ;  and  sometimes  I  have  observed  it  suffi- 
ciently wide  at  its  origin  to  admit  three  fingers.  Morgagni  relates 
several  instances  of  this  affection,  (Epist.  23,  24,  25,  27.)  Most 
of  the  cases  of  dilatation  observed  by  myself  occurred  in  chronic 
affections  of  the  lungs.  Ambrose  Pare  informs  us  that  he  found 
the  arteria  venosa  (which  I  presume,  with  Morgagni,  to  mean  the 
pulmonary  artery)  so  much   dilated  as  to  admit  the  hand,  and 

*  For  two  singular  cases  of  contraction  of  the  pulmonary  artery,  see  the  Mcdi- 
ral  Gazette,  vol   ii   p.  220,  July,  1828.— Transl. 


740  DISEASES    OF    THE    AORTA. 

ossified  on  its  internal  surface.  A  case  is  recorded  in  the  Ephem. 
Cur.  Nat.  (Dec.  iii.  ann.  vi.  obs.  207)  which  would  seem  to 
prove  the  possibility  of  aneurism  taking  place  in  the  pulmonary 
artery.  "  Arteria  pulmonalis  tarn  copioso  sanguine  turgescebat7 
ut,  quasi  aneurismate  affecta,  praeter  propriam  magnitudinem 
praeternaturalem,  liinc  inde  sacculos  cruore  coagulato  turgidos 
habuerit  appensos." 

I  have  never  witnessed  any  symptom  which  could  be  referred 
to  the  dilatation  of  the  pulmonary  artery.  And,  indeed,  the 
affection  is  almost  always  combined  with  some  more  serious  dis- 
ease of  the  lungs  or  heart.  A  similar  conclusion  may  be  drawn 
from  the  cases  noticed  by  Morgagni. 

The  Pulmonary  Veins. — Sometimes  we  find  the  pulmonary 
veins  dilated  in  a  greater  or  less  degree  ;  but  only  in  the  case  of 
organic  disease  of  the  heart,  particularly  of  the  left  cavities.  In 
the  case  of  a  young  woman  who  died  suddenly,  after  having  ex- 
hibited all  the  symptoms  of  diseased  heart,  Chaussier  (Mem.  de 
l'Acad.  1748)  found  the  pulmonary  veins  dilated  (as  were  also 
the  left  ventricle  and  auricle)  and  one  of  them  ruptured  just  as  it 
leaves  the  lungs.  The  original  cause  of  all  this  mischief  was 
ossification  of  the  sigmoid  valves  of  the  aorta. 


CHAPTER  XXVII. 

OF    THE    ORGANIC    DISEASES    OF    THE    AORTA. 

I  formerly  took  notice  of  inflammation  of  the  inner  mem- 
brane of  the  aorta,  and  of  the  small  suppurating  pustules  which 
sometimes  form  in  its  coats  and  open  on  its  internal  surface.  I 
have  also  mentioned  the  bony  incrustations  that  occur  in  it ;  but 
these  as  well  as  some  of  its  other  affections  merit  further  detail  in 
this  place. 

Sect.  I. — Bony,  Cartilaginous,  and  Calcareous  Incrustations 
of  the  Aorta. 

These  formations  belong  to  the  class  of  imperfect  ossifications. 
They  are  of  an  irregularly  flattened  form ;  and  when  they  are  of 
unequal  thickness  they  project  rather  towards  the  outside  than 
the  inside  of  the  vessel.  They  are  situated  between  the  internal 
and  middle  coat,  and  being  as  it  were  encased  in  this  latter,  they 
sometimes  retain  the  impression  of  its  circular  fibres  on  their 
oiter  surface.     Their  inner  surface  is  sometimes  smooth,  and 


DISEASES    OF    THE    AORTA. 


741 


evidently  covered  by  the  internal  coat  of  the  vessel ;  in  other 
cases,  it  is  rough,  and  seems  to  have  partially  destroyed  this 
lunic  by  its  asperities.  In  examining  cases  of  this  kind  minutely, 
we  can  perceive  many  different  points  of  ossification,  which  ex- 
tending themselves  in  their  superficial  diameter,  reunite  and 
form  incrustations  of  a  larger  size.  In  some  instances  these  in- 
volve nearly  the  whole  circumference  of  the  vessel,  and  thus  form 
a  fourth  tunic  of  a  bony  character.  The  cartilaginous  incrusta- 
tions are  the  rudiments  of  the  bony ;  their  situation  and  mode  of 
growth  are  the  same.  They  are  much  softer  than  natural  carti- 
lages, and  are  transformed  into  bone  without  even  acquiring  this 
degree  of  consistence.  In  becoming  ossified,  small  specks  of  cal- 
careous phosphate  are  first  deposited,  and  these  by  their  gradual 
extension  and  union  finally  convert  the  whole  into  a  homogene- 
ous mass.  Sometimes  these  incrustations  seem  to  be  produced 
without  any  previous  formation  of  cartilage,  being  deposited  in 
the  form  of  an  impalpable  and  very  humid  powder  between  the 
ianer  and  middle  coats ;  and  we  frequently  find  a  layer  of  this 
sort  beneath  the  cartilaginous  plates. 

These  bony  incrustations  are  found  frequently  loose  at  their 
circumference,  in  consequence  of  rupture  of  the  internal  coat  of 
the  artery.  This  separation  (which  seems  to  be  one  of  the  most 
common  causes  of  false  aneurisms)  leaves  a  little  cavity,  which 
becomes  filled  with  lymph,  sometimes  intermixed  with  phosphate 
of  lime.  This  matter  has  been  denominated  atheromatous,  and 
the  parts  containing  it  ulcers,  by  many  observers.  And,  indeed, 
it  is  probable  that  in  extensive  separations  of  long  standing,  the 
parts  in  question  may  assume  an  ulcerated  character.  Very  fre- 
quently, however,  these  characters  do  not  exist ;  in  every  case, 
the  affection  in  the  first  instance,  is  the  consequence  of  the  mecha- 
nical separation  of  the  scale  as  formerly  mentioned  ;  and  if  inflam- 
mation even  occurs,  it  is  the  effect  and  not  the  cause  of  the  solu- 
tion of  continuity.  We  can  at  any  time  produce  similar  exfolia- 
tions by  pressing  gently  between  the  fingers,  an  aorta  containing 
similar  incrustations.  And  yet  these  very  lesions  are  the  only 
grounds  on  which  many  authors  build  their  opinion  of  ossification 
of  the  arteries  being  the  result  of  the  inflammation  of  these. 
Kreysig  imagines  that  these  scales  are  produced  by  the  gouty  in- 
flammation alone.  Others,  and  particularly  Bouillaud,  consider 
them  as  the  consequence  of  common  inflammation,  an  opinion 
which  was  formerly  the  general  one  regarding  all  accidental  pro- 
ductions. It  must,  however,  be  admitted,  that  these  bodies  are 
almost  always  formed  without  any  general  or  local  symptom  of 
their  existence,  and  indeed  very  frequently  in  persons  who  enjoy 
the  most  perfect  health. 

Tuberculous  and  cancerous  producti|ns  of  the  aorta  are  very 


742  ANEURISM    OF    THE    AORTA. 

rare :  I  have  met  with  some  of  a  small  size,  however,  in  the  cel- 
lular coat. 

Sect.  II. — Malformation  of  the  Aorta. 

I  have  already  noticed .  the  congenital  smallness  of  the  aorta, 
considered  by  Corvisart  as  one  of  the  most  frequent  causes  of 
aneurism  of  the  heart.  I  have  seen  cases  of  this  kind  in  which 
the  diameter  of  the  vessel  was  hardly  eight  lines.  This  contracted* 
state  is  commonly  equal  throughout,  or  at  least  varies,  only 
according  to  the  natural  size  of  the  vessel  in  different  parts.  In 
three  or  four  cases,  however,  I  have  observed  a  singular  deviation 
from  this  rule.  In  these,  the  aorta  immediately  below  its  arch 
became  suddenly  contracted  to  the  size  of  the  finger,  and  gradually 
diminishing  from  this  point,  it  retained  only  the  size  of  a  swan's 
or  even  a  goose's  quill  by  the  time  it  had  given  off  the  cceliac 
artery.  In  these  cases  the  arch  of  the  aorta  was  dilated,  and 
there  existed  hypertrophy  of  the  heart.  In  some  few  cases  the 
aorta  has  been  found  completely  obliterated.  A  case  of  this  kind 
is  related  in  the  Journ.  de  Med.  t.  xxxiii.  bull.  4  ;  another  by 
Dr.  Graham,  in  the  Medico-Chirurgical  Transactions ;  and  a 
third  by  Mr.  John  Bell.  Sir  A.  Cooper,  in  the  same  work,  no- 
tices a  partial  deformity  of  the  same  kind ;  and  one  was  lately 
observed  by  myself,  in  which  there  existed  a  depression,  of  the 
size  of  an  almond,  at  the  point  of  junction  of  the  ductus  arteriosus. 

Sect.  III. — Aneurism  of  the  Aorta.* 

I  Anatomical  characters. — In  the  following  observations  I  shall 
adhere  to  the  ancient  distinction  of  true  and  false  aneurisms, — 
the  former  comprehending  dilatation  without  rupture  of  any 
of  the  arterial  coats,  the  latter  dilatation  with  rupture  of  some  of 
the  coats.  True  aneurism  of  the  ascending  portion  and  arch  of 
the  aorta  is  very  common.  The  dilatation  usually  extends  from 
the  origin  of  the  artery  to  the  point  where  it  begins  to  descend. 
This  dilatation  rarely  proceeds  so  far  as  to  produce  very  serious 
symptoms,  the  extreme  point  of  dilatation  of  the  artery  not  being 
wider  than  from  two  to  three  fingers'  breadth.  The  convexity 
of  the  arch  and  anterior  part  of  the  artery  appear  to  yield  more 

*  This  section  is  considerably  abridged,  because  it  is  presumed  most  English 
readers  already  possess  superior  information  on  the  subject  of  it,  in  the  classical 
works  of  Scarpa  and  Hodgson.  See  "  A  treatise  on  the  Anatomy,  Physiology, 
&c.  of  Aneurism,"  by  Ant.  Scarpa,  translated  by  J.  H.  Wishart,  and  "  A  Trea- 
tise on  the  Diseases  of  the  Arteries  and  Veins,"  by  J.  Hodgson,  Loud.  1815. 
See  also  Burns,  Op.  Cit.  p.  203,  and  Freer's  work  on  Aneurism,  Birmingham, 
1797.  To  these  works  I  may  now  add  the  very  valuable  work  of  Dr.  Hop. 
the  diseases  of  the  heart  and«rcal  vessels."— Tmnsl . 


ANEURISM    OF    THE    AORTA. 


743 


than  the  other  parts  of  the  vessel.  When  the  dilatation  exists  in 
the  descending  aorta,  it  assumes  the  form  of  an  ovid  tumor, 
gradually  terminating,  at  each  extremity,  in  the  undilated  artery. 
It  is  not  uncommon  to  find  several  dilatations  of  this  kind  in  the 
same  artery.  Sometimes  we  find  the  whole  tract  of  the  aorta 
dilated  to  double  its  natural  size.  Dilatation  in  the  arch  of  the 
aorta,  in  the  degree  above  described,  is  very  common ;  but  this 
is  not  usually  named  aneurism,  unless  it  arrives  at  a  considerably 
greater-  extent.  These  aneurisms  are  sometimes  very  large.  M. 
Corvisart  records  one  double  the  size  of  the  heart,  and  I  have 
seen  them  as  large  as  the  head  of  a  full-grown  foetus.  When  the 
true  aneurism  acquires  a  certain  size,  the  inner  coat  is  often  rup- 
tured, and  false  aneurism  ensues.  The  true  aneurism  is  com- 
monly accompanied  with  a  morbid  degeneration  of  the  internal 
tunic  of  the  artery.  It  exhibits  spots  of  a  bright  red,  slight 
cracks,  and  a  great  number  of  small  ossified  points.  These  latter 
are  usually  considered  as  existing  in  the  substance  of  the  inner 
coat,  but  they  are,  in  truth,  situated  between  it  and  the  middle 
coat.  The  false  aneurism  of  the  aorta,  consequent  to  the  true, 
is  rarer  than  the*  simple  dilatation  of  that  artery  ;  but  it  is  much 
more  common  than  that  greater  degree  of  simple  dilatation  which 
alone  usually  claims  the  name  of  aneurism.  The  false  aneurism 
is  most  common  in  the  ascending,  and  the  true  in  the  descending 
aorta.  I  have  never  met  with  any  other  species  of  false  aneurism 
in  the  ascending  aorta  or  its  arch,  but  that  consequent  to  the 
true,  or  simple  dilatation  of  the  part.  In  tke  descending  aorta, 
however,  false  aneurism  often  takes  place  without  any  previous 
dilatation.  The  opinion  at  present  current  in  the  Parisian  schools, 
viz.  that  in  aneurism  the  internal  coat  remains  entire,  and  pro- 
trudes, in  the  form  of  a  hernia,  through  the  ruptured  fibrinous 
tunic,  is  more  untenable,  as  a  general  position,  than  that  of  Scar- 
pa, who  maintains  the  rupture  of  the  two  internal  tunics  in  every 
case  of  the  disease.  Both  these  opinions  are  true  in  certain  cases, 
but  not  in  all. 

Aneurisms  of  the  aorta  produce  various  effects  on  the  adjacent 
organs,  according  to  their  volume  and  position.  Simple  dilata- 
tion, when  in  a  moderate  degree,  hardly  produces  any  effect,  but 
the  most  inconsiderable  false  aneurisms  may  give  rise  to  very 
serious  disorder.  The  first  and  most  common  of  these  effects  is 
compression  of  the  heart  and  lungs.  When  the  aneurism  is  in 
contact  with  the  lungs,  it  most  commonly  merely  compresses 
them  ;  sometimes,  however,  the  substance  of  these  organs  gives 
way,  and  the  aneurism,  when  it  bursts,  pours  its  blood  directly 
into  the  air-cells.  Frequently  the  aneurism  compresses  the 
trachea,  or  one  of  the  two  bronchial  trunks,  flattens,  and  even- 
tually destroys  a  part  of  them,  and  death  ensues  by  a  species  of 


744  ANEURISM    OF    THE    AORTA. 

haemoptysis  from  the  rupture  of  the  tumor:  The  same  thing  oc- 
casionally happens  with  the  oesophagus,  but  not  so  frequently.  I 
have  only  met  with  three  instances  of  death  from  this  cause.  The 
ordinary  effect  of  these  aneurisms  on  the  heart,  is  to  displace  it 
more  or  less,  downwards  or  to  one  side.  Sometimes  the  aneurism 
bursts  into  the  pericardium  ;  (See  Morgagni  and  Scarpa ;)  but  I 
have  never  met  with  an  example  of  this.  A  case  is  on  record  of 
an  aneurism  of  this  kind  bursting  into  the  pulmonary  artery.* 
The  left  cavity  of  the  pleura  is,  by  far,  the  most  frequent  situa- 
tion for  the  rupture  of  these  aneurisms.  I  have  met  with  one 
case  where  the  aneurism  compressed  and  destroyed  the  thoracic 
duct ;  and  M.  Corvisart  notices  a  fatal  case  of  compression  of  the 
superior  vena  cava  from  the  same  cause.  The  most  remarkable 
local  effects  of  aneurisms  of  the  aorta,  are  those  on  the  vertebral 
column.  They  often  destroy  this  to  a  very  great  depth.  This 
destruction  is  entirely  the  work  of  interstitial  absorption,  there 
never  being  any  mark  of  caries.  On  the  side  next  the  vertebrae 
the  sac  is  completely  destroyed,  and  the  circulating  blood  is 
bounded  by  the  naked  bone.  Aneurisms  of  the  ascending  aorta 
destroy,  in  like  manner,  the  sternum  by  their  pressure,  so  that 
they  come  at  length  to  be  covered  merely  by  the  skin.  I  have 
met  with  two  or  three  tumors  of  this  sort  so  large  that  they 
could  not  be  completely  covered  by  both  hands.  The  aneurisms 
of  the  arch  of  the  aorta,  and  of  the  arteria  innominata,  sometimes 
project,  in  like  manner,  at  the  top  of  the  sternum  or  above  it,  or 
under  the  cartilages  ©f  the  first  false  ribs  of  the  right  side.  It  is 
not  always  the  largest  aneurisms  that  most  readily  make  their 
way  externally.  Sometimes  those  of  the  size  of  an  egg  produce 
this  effect,  whilst,  occasionally,  those  of  the  size  of  the  head  of  a 
full-grown  foetus  remain  quite  covered,  and  are  even  compressed 
by  the  sternum. . 

Signs. — There  are  few  diseases  so  insidious  as  this.  It  cannot 
certainly  be  known  till  it  shows  itself  externally.  It  can  hardly 
be  suspected,  even  when  it  compresses  some  important  organ  and 
greatly  deranges  its  functions.  When  it  produces  neither  of  these 
effects,  the  first  indication  of  its  existence  is  often  the  death  of 
the  individual  as  instantaneously  as  if  by  a  pistol-bullet.  I  have 
known  persons  cut  off  in  this  manner,  who  were  believed  to  be 
in  the  most  perfect  health,  and  who  had  not  complained  of  the 
slightest  indisposition.  We  must,  therefore,  admit  that  aneurism 
of  the  aorta  has  no  symptoms  peculiar  to  it ;  all  those  noticed  by 
authors,  and  especially  by  M.  Corvisart,  being  indicative  merely 
of  the  change  or  compression  of  adjoining  organs.  This  will  be 
evident  by  the  enumeration  of  the  principal  of  these,  viz.  oppres- 

*  Bulletin  ilc  la  Faculte  do  Med.  1819. 


ANEURISM    OF    THE    AORTA. 


745. 


sion  on  the  chest, — dissimilarity  of  the  pulse  in  both  arms, — a 
whizzing  or  rushing  at  the  top  of  the  sternum,  perceptible  by  the 
hand, — obscure  sound  on  percussion, — ^rattling  in  the  throat,  and 
dragging  downwards  of  the  larynx,  when  the  tumor  compresses 
the  trachea,  &c.  After  what  has  been  said  of  the  symptoms  of 
other  diseases  of  the  chest,  I  need  not  remark  how  very  equivocal 
all  these  arc.  In  the  present  state  of  our  knowledge  there  assur- 
edly exists  no  certain  means  of  ascertaining  the  existence  of  this 
disease  until  it  shows  itself  externally.  Even  when  the  aneuris- 
inal  tumor  has  made  its  way  through  the  parietes  of  the  chest,  it 
is  not  always  distinguishable  from  tumors  of  a  different  kind. 

Percussion  will  certainly,  in  some  cases,  enable  us  to  detect  a 
tumour  of  a  large  size,  existing  within  the  mediastinum,  or  even 
in  Ihe  back;  but  not  to  discriminate  the  nature  of  the  swelling. 
Hitherto,  my  experience  has  been  insufficient  to  enable  me  to  say 
how  far  the  difficulty  of  diagnosis  is  likely  to  be  removed  by  the 
use  of  the  stethoscope.  Since  my  employment  of  this  instrument 
I  have  met  with  about  thirty  cases  of  what  I  conceived  to  be 
aneurisms  of  the  aorta.  Most  of  these  left  the  hospital  after 
obtaining  relief  by  bloodletting  and  proper  diet.  In  some  in- 
stances of  moderate  dilatation  of  the  arch,  I  was  enabled  to  verify 
by  dissection  my  previous  diagnosis  afforded- by  the  stethoscope; 
and  in  two  which  showed  themselves  externally,  I  have  had  an 
opportunity  of  testing  still  further  the  stethoscopic  signs.  In  the 
last  cases  I  found  the  pulsations  of  the  tumor  perfectly  isochro- 
nous with  the  pulse  at  the  wrist ;  they  gave,  at  the  same  time,  a 
much  greater  impulse  and  louder  sound  than  the  mere  contrac- 
tion of  the  ventricles  ;  and  the  contraction  of  the  auricles  was 
not  at  all  perceptible.  This  pulsation  which  I  shall  call  simple, 
in  opposition  to  that  of  the  heart,  which  is  double,  (including 
the  alternate  contraction  of  auricles  and  ventricles)  was  dis- 
tinctly perceptible  between  the  right  scapula  and  the  spine, 
— the  purring-thrill  and  bellows-sound  frequently  exist  in 
aneurisms  of  the  aorta  and  other  arteries ;  but  it  will  be  under- 
stood from  previous  remarks  on  these  phenomena,  that  they  can- 
not be  any  signs  of  this  disease.  In  some  cases,  the  simple  pul- 
sation and  greater  impulse  may  indicate  the  disease,  but  even 
this  sign  will  be  often  wanting.  In  fact,  in  the  case  of  enlarge- 
ment of  the  heart,  even  in  a  slight  degree,  the  contractions  of  its 
cavities  will  be  audible  over  the  whole  sternum,  and  under  the 
clavicles  ;  and  as  the  contraction  of  the  ventricles  is  isochronous 
with  the  pulsation  of  the  aneurism,  these  will  necessarily  be  con- 
founded together;  on  the  other  hand,  the  contraction  of  the  au- 
ricles being  heard  through  the  tumor,  we  shall  thus  have  two 
sounds  answering  to  those  of  the  heart,  and  which  will  be  mis- 
taken foi  them. 

94 


746  ANEURISM    OF    THE    AOIH  \ 

Another  sign,  however,  still  remains,  and  although  less  marked 
than  the  simple  pulsation  above  mentioned,  is,  at  least,  as  satis- 
factory ;  it  is  this :  if  we  find  under  the  sternum  or  below  the 
right  clavicle,  the  impulse  of  the  circulatory  organ  isochronous 
with  the  pulse,  and  perceptibly  greater  than  that  of  the  ventri- 
cles examined  in  the  region  of  the  heart,  we  have  reason  to  suspect 
dilatation  of  the  ascending  aorta,  or  arch, — the  more  so,  as  it  is 
extremely  rare  to  feel  the  impulse  of  the  organ  of  circulation 
beyond  the  region  of  the  heart,  even  in  cases  of  the  most  marked 
hypertrophy.  If  this  phenomenon  is  found  constant,  after  re- 
peated examinations,  we  may  consider  the  diagnosis  as  certain. 

Aneurisms  of  the  descending  aorta,  particularly  those  which 
destroy  the  spinal  column,  may  sometimes  be  recognized  by 
means  of  simple  pulsations  opposite  the  tumor.  Aneurisms  of 
the  abdominal  aorta  are  recognized  with  the  utmost  facility  by 
means  of  the  stethoscope.  In  this  case  we  are  sensible  of  tremen- 
dous pulsations,  which  painfully  affect  the  ear,  and  the  intensity 
of  which  is  not  at  all  recognized  by  the  hand,  even  when  they 
are  sufficiently  perceptible  to  the  touch.  These  pulsations  are 
simple ;  and  even  when  the  tumor  is  as  high  up  as  the  origin 
of  the  cceliac  artery,  the  contractions  of  the  auricles  are  not  at 
all  perceptible.  The.sound  which  attends  the  pulsations  of  the 
tumor  is  commonly  clear  and  loud,  like  that  of  the  auricles,  but 
louder.* 

*  Bertin  considers  our  author  as  undervaluing  the  powers  of  the  stethoscope, 
in  detecting  aneurisms  of  the  aorta.  He  says  his  own  experience,  in  this  par- 
ticular obliges  him — "  to  take  the  part  of  auscultation  against  its  very  discov- 
erer;"— and  adds  that  by  means  of  it  "  the  diagnosis  of  aneurisms  oft  the  aorta 
is  not  more  difficult  than  that  of  diseases  of  the  heart  or  lungs." — Op.  C*t.  p.  143. 
In  two  of  M.  Bertin's  cases  (obs.  37,  38)  he  formed  a  correct  diagnosis  of  the 
disease  in  i^jearlier  stages,  that  is,  before  it  had  shown  itself  externally. 

My  brother-annotator,  Dr.  M.  Laennec,  agrees  with  Bertin  and  Bouillaud  in 
thinking  aneurism  of  the  aorta  more  easily  detected  than  our  author  is  willing  to 
allow.  Indeed  he  goes  so  far  as  to  say,  that  "  it  is  so  uncommon  that  there  is  not 
perceptible  in  these  cases  (at  least  when  the  aneurism  has  reached  a  certain 
size,)  either  a  dull  sound  or  single  pulsation,  or  both  conjoined,  that  it  must  be  for 
want  of  looking  for  them  that  they  are  not  found."  Dr.  Hope  is  equally  confi- 
dent of  the  powers  of  auscultation  to  detect  aneurisms  of  the  aorta  ;  and  we  par- 
ticularly recommend  to  the  reader's  attention  his  observations  on  this  subject  in 
his  Treatise  of  Diseases  of  the  Heart,  and  in  his  excellent  article  on  Aneurism 
of  the  Aorta  in  the  first  volume  of  the  Cyclopaedia  of  Pract.  Med.  "  It  is  unimpor- 
tant says  Dr.  Hope,  "  whether  the  pulsations  be  '  simple'  or  '  double  ;'  for  though 
double,  they  may  be  distinguished  from  the  beating  of  the  heart  by  unequivocal 
criteria."  I  can  only  find  room  for  a  brief  notice  of  these  criteria,  and  of 
some  of  the  principal  signs,  which  I  shall  give  in  the  author's  own  words : — 1. 
The  first  aneurismal  sound,  coinciding  with  the  pulse,  is  invariably  louder 
than  the  healthy  ventricular  sound,  and  generally  louder  than  the  most  con- 
siderable bellows-murmur  of  the  ventricles.  2.  On  exploring  the  aneurismal 
sound  from  its  source  towards  the  region  of  the  heart,  it  is  found  progressively 
to  decrease,  until  it  either  becomes  totally  inaudible  or  is  lost  in  the  predomi- 
nance of  the  ventricular  sound.  Now  if  the  sound  emanated  from  the  heart 
alone,  instead  of  decreasing  it  would  increase  on  approximating  towards  the 
precordial   region.     3.  The   second   sound   actually  does   sustain  this   progres- 


ANEURISM    OF    THE    AORTA.  *^i 


Of  all  the  severer  organic  lesions  of  the  thoracic  organs,  three 
only  remain  without  pathognomonic  signs  to  those  who  are  versed 
in  the  practice  of  percussion  and  auscultation.  These  are 
aneurism  of  the  aorta, — pericarditis — and  polypi  of  the  heart ; 
all  of  which,  it  may  be  remarked,  are  very  liable  to  be  confounded 
together.  1  will  here  detail  a  remarkable  mistake  of  this  kind. 
'In  1819  I  was  consulted  in  the  case  of  a  young  woman,  who  had 
exhibited  for  eight  months  the  general  symptoms  of  diseased 
heart.  I  found  the  action  of  this  organ  regular,  and  accompanied 
by  a  natural  degree  of  impulse  and  sound.  The  right  and  left 
precordial  regions  sounded  well  on  percussion  ;  but  immediately 
above  these,  the  sternum  as  high  up  as  the  second,  rib,  and  the 
whole  surface  of  the  chest  corresponding  with  the  cartilages  of 
the  second,  third,  fourth,  and  fifth  ribs  on  the  left  side,  yielded  a 
completely  dead  sound.  Over  the  same  space,  the  pulsations  of 
the  heart  were  much  louder  than  in  the  cardiac  regions,  and  were 
not  simple.  Notwithstanding  this  last  circumstance,  I  imagined 
that  there  existed  an  enormous  aneurism  of  the  ascending  aorta. 
I  did  not  see  the  patient  again ;  and  she  died  a  few  months  after 
my  examination.  Upon  dissection,  the  aorta  was  found  perfectly 
sound.  The  tumor  which  had  destroyed  the  natural  resonance 
of  the  chest,  was  the  pericardium,  enormously  distended  by  sero- 
purulent  fluid,  and  which  extended  to  the  top  of  the  chest.  The 
heart  was  invested  by  false  membranes  of  a  yellowish  color,  some- 

sive  augmentation  on  advancing  towards  the  heart ;  and  as  its  nature  and  rythm 
are  found  to  be  precisely  similar  to  those  of  the  ventricular  diastole  heard  in  the 
precordial  region,  it  is  distinctly  identified  as  the  diastolic  sound.  The  second 
Euiid, he  efore/corroborates  rather  than  invalidates  the  evidence  of  aneurism 
afforded  by  the  first;  for  if  both  sounds  proceeded  from  the  heart,  both  would 
on  approximating  towards  it  or  on  receding  from  it,  sustain  the  same  progressive 
changes  of  intensity.  4.  Another  distinctive  characteristic  of  the  aneunsma 
nuSion  s  the  peculiar  nature  of  its  sound.  It  is  a  deep  hoarse  tone  of  short 
duS  on  with  ail  abrupt  commencement  and  termination,  and  generally  louder 
fhan  he'mo  considerable  bellows-murmur  of  the  heart.  It  accurately  resem- 
bles tie Zptl  of  a  sounding  board  heard  from  a  distance ;  whereas  the  sound 
occasoned  by  valvular  disease  of  the  heart  has  more  analogy  to  the  be  ows-mur- 
mu beZ  somewhat  soft  and  prolonged,  with  a  gradual  swell  and  fall.  When 
X  oik tattonTs  confined  to  the  ascending  aorta,  the  sound,  impulse,  and  purring 
temc Tare  stronger  on  the  right  than  on  the  left  side  of  the  neck  and  the 
«m,nd  alon-  the  sternum  is  superficial  and  of  a  whizzing  or  hissing  character. 
The  loudest  aneurismal  sound  is  that  occasioned  by  dilatation,  and  it  has  more 
of 'the era in*  or  rasping  character  in  proportion  as  the  mterior  of  the  vessel  is 
leofersprtad  with  lard  and  especially  osseous  asperities.  Old  aneurisms, 
Z  narietes  of  which  are  thickened  by  fibrinous  depositions,  yield  only  a  dull 
™d  remote  sound.  In  all  cases  of  dilatation  and  in  the  majority  of  sacculated 
aneurTm the "sound  is  loudest  above  the  clavicles,  even  though  the  impulse  be 
stronger  below  The  sound  is  in  most  instances  audible  on  the  back  ;  and  when 
stronger  Deiuw.  ./.,,•  aorta  and  s  extended  along  the  spine,  it  is 
the  tumor  m™?™1^**™^^™?  If  it  possesses  in  the  back  the  abrupt 
often  louder  J^Jj^^JJKit  afford/is  almost  positive  ;  for  the  loud- 
'TnLlTthe  h  arf  wh  n  lmard  on  the  back,  are  so  "softened  and  subdued 
^ril  toulirtotse  their  harshness.-Cyc.  of  Pract.  Med.  vol.  ,.  p. 
112. — Transl. 


748  TREATMENT    OF    DISEASES    OF    THE    HEART. 

what  friable,  and  hardly  more  consistent  than  thick  pus,  and  was 
separated  from  the  pericardium  only  by  a  very  small  quantity  of 
serum.  This  pericarditis  had  never  presented  the  character  of  an 
acute  disease  ;  and  the  treatment  of  Valsalva,  persevered  in  for  sev- 
eral months,  in  the  intention  of  combatting  the  supposed  aneurism, 
had  no  effect  in  retarding  its  progress. 


CHAPTER  XXVIII. 

OF    THE    TREATMENT    OF    THE    ORGANIC    DISEASES    OF    THE 
HEART. 

The  frequent  co-existence,  in  the  same  subject,  of  several  of  the 
organic  affections  of  the  heart,  and  the  absolute  incurability  of  the 
greater  number  of  them,  have  induced  me  to  bring  under  one 
head,  in  the  present  chapter,  all  that  I  have  to  say  relative  to  their 
treatment. 

Of  all  these  organic  lesions,   hypertrophy,  either  simple  or 
combined  with  dilatation,  appears  to  me  most  susceptible  of  cure. 
The  greater  number  of  practitioners  are  too  much  in  the  habit 
of  despairing  of  success  in  cases  of  this  kind,  and,  therefore,  con- 
tent themselves  with  attacking  such  urgent  symptoms  as  may 
arise  in  their  progress.     And  yet,  I  believe,  there  is  no  one  who 
has  not  succeeded,  every  now  and  then,  even  by  this  sympto- 
matising  treatment,  in  prolonging  for  fifteen  or  twenty  years,  the 
lives  of  individuals  affected  with  organic  disease  of  this  important 
organ.     In  courageously  and  perseveringly  applying  to  the  treat- 
ment of  hypertrophy,  the  method  recommended  by  Valsalva  and 
Albertini  against  aneurism  of  the  arteries,  we  may  look  for  much 
more  frequent  and  complete  success ;  more  especially  if  we  begin 
the  use  of  these  means  at  a  period  when  the  disease  has  not  as 
yet  produced  any  severe  disorder  of  the  general  system.     But  to 
obtain  success  in  this  way,   it  is  necessary  that  the  physician  and 
patient  should  be  armed  with  great  and  almost  equal  courage  ;  for 
it  is  hardly  more  difficult  for  the  latter  to  support  continued  starva- 
tion and  repeated  bleedings,  than  it  is  for  the  former  to  hold 
out  against  the  daily  opposition  of  friends  and  relations,  and  the 
discouragement  which  cannot  fail  to  affect  the  patient  in  the  course 
of  a  treatment,  which  must,  at  the  least,  continue  for  some  months, 
and  which  it  is  sometimes   necessary  to  persevere  in   for  several 
successive  years. 

This  plan  must  be  carried  into  effect  with  activity,  especially 
at  the  beginning ;  and  there  is  much  more  fear  that,  in  our  en- 


TREATMENT    OF    DISEASES    OF    THE    HEART. 


749 


deavors  to  reduce  the  patient,  we  should  stop  short  of   the  mark, 
than  that  we  should  go  beyond  it.     Accordingly  we  begin  the 
treatment  by  as  large  a  bloodletting  as  the  patient  can  bear  with- 
out fainting,  and  repeat  this  every  second,  fourth,  or  eighth  day, 
at  most,  until  the  palpitations  have  ceased,  and   the  heart  only 
yields  a  moderate  impulse  under  the  stethoscope.     At  the  same 
time   we  diminish,  by  one  half,  the  ordinary  quantity  of  food 
used  by  the  patient;  and  we  even  make  still  greater  reduction,  if 
he  retains  more  muscular  strength  than  is  barely  sufficient  to 
enable  him  to  take  a  few  minutes'  walk  in  the  garden.     In  the 
case  of  an  adult  in  full  strength,  I  usually  reduce  the  quantity  of 
food  to  fourteen  ounces  per  day,  in  which  allowance  only  two 
ounces  of  white  meat  are  permitted.     If  the  patient  prefers  broth 
or  milk,  I  reckon  four  ounces  of  these  liquids  for  one  of  meat. 
Wine  is  entirely  forbidden.*     When  the  patient  has  been  two 
months  without  experiencing  palpitations  and  without  increased 
impulse  of  the  heart,  we  may  lessen  the  frequency  of  the  bleed- 
ings, and  diminish,  in  some  degree,  the  severity  of  the  regimen, 
if  the  patieat  is  not  at  all  habituated  to  or   satisfied  with  his 
allowance.     But  we  must  return  to  the  same  means,  and  with  the 
same  vigor,  if  the  augmented  impulse  of  the  heart  should  re- 
turn.    We  ought  not  to  have  any  confidence  in  the  cure,  until  all 
the  symptoms,  and   particularly  all  the  physical  signs  of  hyper- 
trophy, have  been  completely  absent  for  a  whole  year.     We  must 
take  care  not  to  be   deceived  by  the  complete  calm  which  the 
bloodletting  and    abstinence   sometimes   induce   very   speedily, 
especially  if  the  disease  had  so  far  advanced,  before  we  began 
our  treatment,  as  to  have  induced  extreme  dyspnoea,  anasarca, 
and  other  symptoms  threatening  a  fatal  issue  at  no  distant  date. 
In  cases  of  this  kind,  even  when  anasarca,  ascites,  oedema  of  the 
lungs  and  a  general  cachectic  state  of  the  system  are  present,  we 
must  nevertheless  fearlessly  prosecute  the  plan  of  bleeding  and 
starvation.!     Indeed,  it  is  certain  that,  under  such  circumstances, 

*  Our  author  only  mentions  wine  among  the  forbidden  liquors,  but  he  of 
course  means  to  exclude  equally  every  other  fermented  and  spirituous  liquor. — 
Transl. 

t  For  the  original  account  of  this  macerating  treatment  the  reader  is  referred 
to  the  memoir  of  Albertini  in  the  first  volume  of  the  Commentarii  de  Soc.  Bon- 
oniens.  Scient.  et  Art.  1748,  entitled  "  Animadversiones  super  quibusdam  diffici- 
lis  respirationis  vitiis  a  laesa  cordis  et  picecordiorum  structura  pendentibus."  I 
shall  here  extract  a  single  sentence  :  "  Et  ideo  nos  et  amicissimus  vir  studiorum 
nostrorum  socius  dum  viverat,  A.M.  Valsalva,  cum  in  cadaveribus  offenderemus 
hsec  vitia  saepius  quam  augurabamur,  cepimus  inter  nos,  expensa  laesionis  organi- 
cae  natura,  existimare  conscntaneum  pro  illius  curatione  tutum,  efficax,  quineti- 
am  fortasse  unicum  auxilium  futurum,  si  aegrotans  non  deploratus,  quadraginta 
circiter  dies  in  lecto  decumbens,  praemissa  una  vel  altera  vena?  sectione  praascrip- 
lisque  clysteriis,  et  vini  abstinentia,  tantum  cibi  et  potus  ad  trutinam  dimensi 
quotidie  assumeret,  quantum  vita;  sustinendae  satis  esset;  illudque  non  bipartito 
tantum  indies  distributum,  scd  tripartito,  et  quadripartioetiam,sic  utcxigua  dosi 
sanguifera  vasa  ingrcssum,  ea  turn  ne  mininum  quidem  distendcret.  '     Valsalva 


750  TREATMENT    OF    DISEASES    OF    THE    HEART. 

diuretics  never  act  so  well  as  after  venesection.  We  must  have 
recourse,  in  their  turn,  to  all  the  more  powerful  diuretics,  and  in 
rather  large  doses.  Medicines  of  this  class  are  very  uncertain  in 
their  effects  ;  and  when  we  do  not  find  one  to  answer,  we  must 
try  another.  Accordingly,  we  may  give  a  trial,  in  succession,  to 
nitre,  acetate  of  potass,  squills,  various  plants  of  diuretic  pro- 
perties, and  among  others,  digitalis.  This  last  medicine  is  at 
present  much  used  in  diseases  of  the  heart,  from  a  general  opinion 
that  besides  its  diuretic  effects,  it  possesses  a  sedative  influence 
over  the  heart.  I  must  confess  that  this  influence  has  never  ap- 
peared very  clear  to  me,  certainly  not  constant,  even  when  the 
dose  was  carried  to  the  extent  of  producing  vomiting  and  vertigo. 
I  have  only  remarked,  with  some  others,  that  in  the  first  days  of 
its  administration,  it  frequently  accelerates  the  pulsations  of  the 
heart,  and  seems  subsequently,  in  some  cases,  to  render  them 
slower :  but  I  can  by  no  means  consider  it  as  a  powerful  remedy 
in  hypertrophy  of  this  organ.  I  may  give  a  like  report  of  hy- 
drocyanic acid  and  the  cherry-laurel  water.  It  cannot  be  denied 
that  hydrocyanic  acid  possesses  a  very  considerable  action  on  the 
spinal  marrow,  and  through  it  on  the  heart ;  but  its  very  activity 
prevents  our  employing  it  in  a  concentrated  state  ;  and  when  di- 
luted it  is  very  uncertain  in  its  action.* 

having  been  the  first  who  put  this  method  into  actual  practice,  it  is  usually  cal- 
led by  his  name.  For  further  accounts  of  it  I  refer  to  Morgagni  (Epist.  XVII. 
30,)  who,  as  well  as  Lancisi,  Guattani,  Sabatier,  Pelletan,  Corvisart,  Hodgson, 
Bertin,  &c.  recommend  its  employment,  and  adduce  many  facts  illustrating  its 
utility.  I  have  made  trial  of  it  in  a  modified  degree,  in  hypertrophy  of  the 
heart,  and,  as  I  thought,  with  much  temporary  benefit ;  but  I  have  found  very 
few  of  my  patients  possessed  of  sufficient  courage  or  faith  to  submit  to  it,  even 
in  a  modified  degree,  for  any  considerable  length  of  time.  The  principle  of  this 
practice,  simple  as  it  is,  would  seem  to  be  strangely  misunderstood  by  some 
practitioners.  Some  time  since  a  patient  affected  with  hypertrophy  came  to  me 
here  for  advice  ;  he  had  been  recently  under  the  care  of  a  physician  in  London, 
who  had  iiim  largely  bled  at  every  visit,  but  did  not  restrict  him  in  any  respect 
as  to  his  diet  or  bodily  exercise. 

Some  practical  physicians,  however,  are  led  by  experience  to  regard  the  mac- 
erating practice  of  Albertini  and  Laennec  as  positively  injurious,- even  in  the 
cases  wherein  it  has  been  most  strenuously  recommended.  See,  for  instance, 
an  observation  of  Dr.  Stokes  to  this  effect  in  an  excellent  memoir  by  him  on 
the  subject  of  aneurism,  in  the  15th  No.  of  the  Dublin  Medical  Journ.  Dr. 
Charles  Williams  likewise  informs  me  that  he  has  repeatedly  observed  many 
diseases  of  the  heart  and  large  vessels  to  be  aggravated,  and  their  progress  has- 
tened, by  the  system  of  starvation.  "I  have  now,"  he  says,  "several  patients 
with  valvular  disease,  who  are  at  this  time  tolerably  comfortable  with  a  dry 
nutritious  diet  and  a  moderate  but  regular  action  on  the  bowels ;  whereas,  some 
time  since,  under  the  starving  system,  the  circulation  lost  its  balance,  the  irrita- 
tion of  inanition  was  added  to  the  distress  from  the  organic  disease,  and  their 
life  was  a  continued  scene  of  misery."  These  observations,  to  the  correctness 
of  which  my  own  more  recent  experience  induces  me  willingly  to  assent,  al- 
though I  cannot  adduce  any  very  positive  evidence  in  corroboration,  are  deserv- 
ing the  greatest  attention  ;  and,  from  the  eminence  of  the  observers,  they  will, 
no  doubt,  command  this.—  Transl. 

*  French  practitioners,  although  in  general  so  fond  of  new  remedies  of  the 
poisonous  class,  and  the  first  to  employ  the  hydrocyanic  acid,  seem  now  much 


TREATMENT    OF    DISEASES    OF    THE    HEART. 


751 


When  diuretics  give  no  relief  in  dropsical  affections,  the  con- 
sequence of  diseased  heart,  purgatives  are  frequently  found  useful ; 
and  we  ought  to  have  the  less  scruple  in  having  recourse  to  them, 
since  their  frequent  repetition  is  sometimes  as  effectual  as  blood- 
letting, in  reducing  the  action  of  the  heart.      On  this  account, 
even  where  there  exists  no  signs  of  dropsy,  if  the  first  bleedings 
are  ineffectual,  one  or  two  purgatives  will  often  render  the  sub- 
sequent one  more  so.     All  sorts  of  purgatives  may  be  useful  in 
the  serous  diathesis  produced  by  disease  of  the  heart,  but  the 
more  potent  drastics,  which  act  in  a  small  compass,  are  in  general 
to  be  preferred.     In  this  case,  likewise,  physicians  are  accustomed 
to  despair  too   soon  of  their  patients,  and  sometimes  abandon 
them  to  certain  death  when  they  might  preserve  their  life,  and 
even  render  it  supportable,  for  several  more  years.     Corvisart, 
who  was  by  no  means  a  timid   practitioner,  committed  an  error 
of  this  kind  in  the  case  of  one  of  his  friends.     This  gentleman 
had  been  for  several  years  affected  with  disease  of  the  heart, 
and   for   some   time    had   labored    under    ascites   and   general 
anasarca,     for   the    removal   of    which,    bloodletting,    diuretics, 
and  some  purgatives,  had  been  unsuccessfully  employed.     Cor- 
visart considered  his  death  as  certain,  and  made  the  patient's 
friends  acquainted  with    his  opinion.       A  few  days  afterwards 
a  quack    was  consulted,  famous  at    that  time  for  his    cures  of 
dropsy.       He  administered  to  the    patient  a  powerfully  drastic 
powder  in  two  ounces  of  brandy,  with  the  immediate   effect  of 
producing  twenty  alvine  evacuations.     From  this  time  the  urine 
became  somewhat  more  copious ;    and  the  same  remedy  being 
repeated  with   similar  effect,    every  day  for   upwards  of  a  week, 
the  dropsical  symptoms  completely  disappeared,  and  the  patient 
afterwards   lived   ten   years  in   a  very  tolerable   state  of  health. 
When  we  have  once   succeeded,  by  means  of  purgatives,  in  aug- 
menting the  flow  of  urine,  it  is  hot  always  requisite  to  continue 

afraid  of  this  remedy.  Dr.  M.'  Laennec,  in  his  note  on  this  passage,  says,  that  so 
many  fatal  results  have  of  late  years  been  experienced  from  its  use,  that  no  pru- 
dent practitioner  now  gives  it  in  diseases  of  the  heart.  I  have  myself  found 
the  hydrocyanic  acid  altogether  inefficient  in  organic  diseases  of  the  heart. 
From  its  undoubted  efficacy,  however,  in  relieving  certain  states  of  disordered 
stomach,  it  is  occasionally  found  a  valuable  remedy  in  those  sympathetic  affec- 
tions of  the  heart  depending  on  this  cause  ;  and  it  has  even  been  proposed  as  a 
sort  of  diagnostic  test,  in  doubtful  cases,  as  to  whether  the  disturbance  of  the 
circulation  is  primary  or  secondary.  See  Dr.  Elliotson's  "Cases  illustrative  of 
the  efficacy  of  Hydrocyanic  Acid  in  Affections  of  the  Stomach.  Lond.  1820."—- 
See  also  Dr.  Johnson's  Review  for  May,  1821,  p.  658. — M.  Broussais  has  re- 
cently recommended  a  new  sedative  remedy  in  diseases  of  the  heart,  viz.  the 
syrup  of  the  common  asparagus;  (Annales  de  la  Med.  Physiol.  Ju ill.  1829;)  a 
medicine  which,  according. to  him,  possesses  the  power  of  quieting  the  action 
of  the  heart  and  rendering  the  pulse  slower,  without  at  all  irritating  the  stom- 
ach. The  plant  eaten  in  the  usual  manner  is  said  to  have  the  same  effect. 
This  statement  of  M.  Broussais,  in  reference  to  the  asparagus  as  a  remedy  of 
power  generally,  in  affections  of  the  heart,  requires  confirmation. — Transl. 


752  TREATMENT    OF    DISEASES    OF    THE    HEART. 

them  for  a  long  period  ;  as  very  often  the  stimulus  conveyed  to 
the  absorbents  by  two  or  three  doses,  will  last  more  than  a  fort- 
night.* 

The  treatment  of  simple  dilatation  of  the  heart  is  much  more 
difficult  and  more  rarely  successful,  even  in  improving  the  con- 
dition of  the  patient,  than  that  of  the  simple  or  even  complicated 
hypertrophy.  When  dilatation  exists  singly,  or  with  very  mark- 
ed preponderance  over  the  accompanying  hypertrophy,  we  must 
be  more  guarded  in  our  bleedings,  and  have  recourse  to  them 
only  after  long  intervals,  and  to  relieve  urgent  symptoms.  In 
this  case  bitters  and  steel  must  be  considered  the  chief  remedies. 
Aromatics  are  also  exceedingly  useful,  and  particularly  the  infu- 
sion of  cat-mint,  (nepeta  cataria,)  valerian,  balm,  and  orange- 
flower.  Steel  and  bitter  preparations  must  be  varied  accord- 
ing to  the  state  of  the  stomach ;  and  at  the  same  time  digitalis 
and  infusion  of  the  flowers  of  the  cherry-laurel,  may  be  given  to 
quiet  the  pulse.  The  existence  of  signs  of  valvular  disease,  or 
of  any  other-  obstacle  to  the  circulation,'  must  not  prevent  us 
from  attacking  with  vigor,  the  accompanying  hypertrophy,  or 
dilatation.  No  doubt,  we  do  not  always  succeed  in  our  endea- 
vors, but,  With  perseverance,  we  do  so  frequently ;  and  even  in 
the  case  just  mentioned  we  occasionally  are  fortunate  enough  to 
prolong  for  an  indefinite  period  the  life  of  our  patient,  and  even, 
in  more  favorable  .circumstances,  to  obtain  a  perfect  cure.  I 
could  here  cite  a  dozen  instances  of  cures  of  hypertrophy, 
either  simple  or  combined  with  dilatation,  which  have  now  stood 
the  test  of  several  years.  I  shall  here  content  myself  with  no- 
ticing one  of  these,  which  is  the  more  conclusive,  inasmuch  as  I 
was  here  enabled  to  verify  the  cure  by  dissection,  the  patient  hav- 
ing afterwards  died  of  another  disease. 

A  nun,  fifty  years  of  age,  had  been  affected  for  twelve  years 
with  all  the  symptoms  of  disease*  of  the  heart,  in  a  very  high  de- 
gree, viz.  strong  and  frequent  palpitations,  habitual  dyspnoea, 
broathlessness  on  using  the  least  exercise,  sudden  starting*  from 
sleep,  almost  constant  oedema  of  the  lower  extremities,  and  livi- 
dity  of  the  cheek,  nose  and  lips.  These  symptoms  had  increased 
during  the  last  year,  so  that  she  could   scarcely  move    from  her 

In  symptomatic  dropsy,  the  consequence  of  diseased  heart,  more  especially 
in  the  form  of  hydro-thorax,  I  have  found  the  infusion  of  digitalis,  in  large  doses 
in  the  manner  recommended    by  Dr.  Maclean,  almost  a    specific  in  carrying    off 
the  water;    and   have  thereby,   to  every  appearance,    prolonged  life   for 
years,  when  things  looked  the  most  unpromising.     In  these  casi  -    I  have  gener- 
ally commenced  the    treatment    by  venesection  and    the   application  of  a  large 
blister  to  the  chest,  over  the  site  of  the  effusion,  as  indicated  by  the  stethoscope 
My  experience  entirely  accords  with    Laennec's  respecting  the  inefficacy  of  dig 
italis,  as.a  direct  remedy  in  hypertrophy  :  indeed,  1  may  saj  .  thai  I  have  in  no 
case  derived  benefit  from   its  employment  in    any  organi    affection  of  the  heart 
or  lungs. — Transl. 


TREATMENT    OF    DISEASES    OF    THE    HEART. 


753 


»;hair  without  the  feeling  of  suffocation.  In  this  state  I  recom- 
mended the  treatment  of  Valsalva,  which  she  agreed  to.  I  im- 
mediately reduced  her  food  to  one-fourth  of  her  former  allow- 
ance, and  bled  her  once  a  fortnight,  cither  from  the  arm  or  by 
leeches.  This  mode  of  treatment  gave  immediate  relief,  and  in 
the  course  of  six  months  all  the  symptoms  had  disappeared ; 
and,  with  the  exception  of  debility,  (which,  however,  was  not 
greater  than  it  had  been  previously,)  she  enjoyed  a  better  state 
of  health  than  for  many  years  before.  The  respiration  was  now 
free,  and  the  palpitations,  osdema,  startings,  and  lividity  of  face 
had  quite  disappeared.  After  this  I  recommended  the  bleedings 
to  be  decreased  in  frequency,  and  I  dispensed  with  them  altoge- 
ther at  the  end  of  a  year.  She  also  returned  gradually  to  her 
old  regimen,  only  that  now  a  much  smaller  quantity  of  food  sat- 
isfied her  appetite.  She  lived  two  years  in  a  state  of  perfect 
health,  and  was  then  suddenly  carried  off  by  an  epidemic  cholera. 
Upon  examining  the  body  after  death,  I  found  the  heart  consi- 
derably less  than  the  closed  hand  of  the  individual,  being  only 
about  the  usual  size  of  that  of  a  child  twelve  years  old,  although 
this  woman  was  five  feet  three  inches  in  height.  The  exterior  of 
the  heart  resembled,  in  appearance,  a  withered  apple,  the  wrinkles 
running  longitudinally.  The  ventricular  parietcs  were  flaccid, 
but  without  any  obvious  softening,  and  of  the  natural  thickness. 
1  am  well  aware  that  nothing  can  be  deduced  from  a  single  case, 
t  but  I  have  thought  the  above  relation  might  be  useful  in  stimulat- 
ing others  to  prosecute  this  subject  more  at  length. 

Softening  of  the  heart  clearly  indicates  the  employment  of 
bitters,  tonics,  and  steel.  Wine  is  also  indicated  in  this  case,  par- 
ticularly if  the  affection  supervenes  to  a  severe  fever,  and  if  the 
patient  bears  it  well. 

Inflammation  of  the  pericardium  presents  the  same  indications 
as  pleurisy,  to  which  I  refer  the  reader ;  as  does  likewise  the  in- 
flammation of  the  inner  membrane  of  the  heart  and  vessels. 
Acute  inflammation  of  the  substance  of  the  heart,  if  it  can  be  re- 
cognized, will  furnish  the  same  indications  as  pneumonia ;  and 
in  regard  to  partial  inflammations  and  ulcerations,  if  they  could 
be  ascertained,  it  is  evident  that  all  that  we  can  do  is  to  lessen 
the  action  of  the  heart  by  rest,  bloodletting,  and  abstinence.* 

"  One  great  principle  always  to  be  kept  in  view  in  the  treatment  of  diseases 
of  the  heart,  is  entirely  overlooked  by  our  author,  and  can  merely  be  glanced 
at  by  me  in  this  place,  although  I  am  fully  aware  of  its  paramount  importance  : 
it  is  the  removal  of  all  disorder  in  other  organs  which  can  act  as  a  source  of 
irritation  to  the  heart.  In  a  former  note  I  briefly  alluded  to  gastric  irritation  as 
a  frequent  concomitant  (and  indeed  cause)  of  disease  of  the  heart ;  and  I  would 
here  add,  that,  from  its  powerful  influence  in  stimulating  the  organs  of  circula- 
tion to  increased  ai  tion,its  previous  cure  becomes  essential  to  the  success  of  our 
measures  lor  remedying  the  disease  of  tho  heart.  The  same  is  true  in  diseases 
in  other  organs ;  but  their  Influence  is  trifling,  compared  with  that  of  disease 
95 


754  TREATMENT    OF    DISEASES    OF    THE    HEART. 

The  experience  of  both  Corvisart  and  Hodgson  proves  that  we 
ought  not  to  consider  aneurism  of  the  aorta  as  absolutely  incu- 
rable ;  and  we  know  that  the  circulation  may  even  be  carried  on 
after  the  obliteration  of  this  artery.  As  soon,  therefore,  as  we 
have  recognized,  or  even  suspected  the  existence  of  this  terrible 
disease,  we  ought  fearlessly  to  have  recourse  to  the  treatment  of 
Valsalva.  Only  we  must  be  careful  not  to  induce  syncope,  par- 
ticularly after  the  first  bleedings,  as  this  might  prove  fatal. 
Where  the  tumor  shows  itself  externally,  the  application  of  ice 
to  it  may  be  beneficial,  as  in  aneurisms  of  the  limbs.  The  acetate 
of  lead  has  been  employed  in  Germany  for  some  years  past  in 
cases  of  aneurism ;  and  with  alleged  success.  I  am  not  aware 
on  what  principle,  this  remedy  was  administered  ;  but  I  had  my- 
self made  previous  use  of  it  in  diseases  of  the  heart,  and  in  ob- 
stinate haemorrhages,  owing  to  some  observations  I  had  made  of 
the  state  of  the  bodies  of  subjects  who  had  died  while  affected 
with  colica  pictorum.  The  only  constant  alteration  I  had  found 
in  these  cases,  were  a  great  paleness  of  all  the  tissues,  and  a  les- 
ser quantity  of  blood  than  is  usually  met  with.  From  these  cir- 
cumstances I  suspected  that  one  of  the  effects  of  lead  on  the 
system  was  to  affect  the  formation  of  blood  and  thereby  lessen  its 
quantity.     In  giving  this  medicine  I  began  with  a  dose  of  three 

of  the  digestive  organs.  I  would,  therefore,  lay  it  down  as  a  general  rule  in 
chronic  affections  of  the  heart,  that,  previously  to  having  recourse  to  any  reme- 
dies intended  to  act  directly  on  it,  we  ought* to  be  assured  that  the  digestive  or-, 
gans  are  in  a  healthy  state, — that  their  mucous  surfaces  are  free  from  irritation, 
— their  vascular  system  not  morbidly  distended,  and  that  the  liver  is  performing 
its  secretory  function  freely  and  regularly.  When  derangements  of"  this  kind 
are  present, — a  few  leeches  to  the  praecordia  or  anus,  some  small  doses  of  oxide 
of  mercury  and  castor  oil,  a  mild  and  spare  diet,  and  bodily  and  mental  repose, 
will  often  do 'more  to  tranquilize  the  circulation  than  more  active  and  rougher 
treatment.  And,  indeed,  in  many  cases,  more  especially  in  the  earlier  stages, 
when  the  stethoscope  gives  us  but  little  information,  it  is  not  until  we  have  re- 
stored the  parts  just  mentioned  to  a  comparatively  healthy  condition,  that  \vc 
can  know  how  far  the  disordered  action  of  the  heart  depends  on  sympathy  with 
these,  or  is  the  consequence  of  incipient  organic  lesion  of  the  heart  itself.  For 
valuable  information  on  this  subject  the_reader  need  hardly  be  referred  to  the 
popular  writings  of  Mr.  Abernethy,  Drs.  Wilson,  Philip,  Johnson,  Hall,  Paris, 
Ayre,  &c.  as  they  are  in  every  body's  hands. 

The  young  reader  will  do  well  also  to  study  the  works  of  M.  Broussais,  which, 
however  disfigured  by  false  theory  and  strained  conclusions,  are  calculated  to 
convey  more  valuable  practical  information  to  a  certain  class  of  English  practi- 
tioners, than  the  writings  of  any  other  modern  author.  If  he  has  not  introduced, 
he  has  at  least  forwarded,  in  a  most  material  degree,  the  vast  improvement  that 
has  taken  place,  of  late  years,  in  the  dietetic  treatment  of  diseases;  an  im- 
provement, a  thousand  times  more  valuable,  than  would  be  the  addition  to  our 
meteria  medica  of  a  thousand  new  remedies  equal  in  power  to  our  best.  From 
the  manner  in  which  the  most  powerful  agents,  remedial  and  dietetic,  were  for- 
merly thrown  into  the  stomach  without  any  seeming  reference  to  their  primary 
action  on  the  first  passages,  one  would  almost  be  disposed  to  think  that  the 
members  of  the  profession  still  shared  the  opinion  of  its  great  founder  respecting 
the  nature  and  powers  of  these  organs:  "  At  vero  venter  a  medicamento  non 
exulceratur.  Nam  res  est  valida  ac  robusta,  nimirum  velut  pellis  et  corium." 
De  Morb.  (Edit.  Vanderlind.)  p.  157.—  Transl. 


NERVOUS    AFFECTIONS    OF    THE    HEART. 


755 


or  four  grains  a  day, — and  I  have  not  yet  carried  it  beyond  six- 
teen grains.  I  have  continued  its  employment  for  several  months, 
without  producing  colic,  or  any  other  symptoms  of  the  saturnine 
disease.  This  remedy  has  frequently  seemed  useful,  but  I  have 
never  found  it  of  very  decided  power. 


CHAPTER  XXIX. 

OF    NERVOUS    AFFECTIONS    OF    THE    HEART    AND    VESSELS. 

The  study  of  pathological  anatomy,  in  making  us  acquainted 
with  the  existence  of  important  organic  lesions  in  many  cases,  in 
which'  practitioners,  too  much  addicted  to  the  exclusive  observa- 
tion of  symptoms,  saw  only  cachexies,  or  alterations  of  the  fluids, 
or  at  least  nervous  affections,  has  made  us  fall  gradually  into  an 
error  of  an  opposite  kind :  and  among  the  present  race  of  our 
pupils,  many  are  as  little  disposed  to  acknowledge  any  nervous 
diseases  besides  the  organic  affections  of  the  nerves,  brain,  and 
spinal  marrow,  as  to  admit  any  primary  morbid  changes  in  the 
fluids  of  the  animal  body.  Nevertheless,  we  are  bound  to  admit, 
that  every  disease  in  which  we  can  discover  no  constant  lesion  of 
the  solids  nor  evident  alteration  in  the  fluids,  must  consist  in  some 
disorder  of  the  nervous  influence.  Of  this  class  are  several  of 
the  affections  of  the  heart  and  arteries  which  I  shall  now  notice. 

Sect.  T. — Neuralgia  of  the  heart. — Angina  pectoris. 

It  is  by  no  means  unusual  to  meet  with  persons  who  suffer, 
either  constantly  or  by  fits,  from  pains  like  those  of  rheumatism, 
or  neuralgia,  in  the  region  of  the  heart,  and  which  are  improperly 
considered  both  by  the  patients  and  their  medical  attendants,  as 
signs  of  organic  disease  in  this  organ.  Sometimes  these  pains 
are  confined  to  this  spot,  but  frequently  they  extend  at  the  same 
time,  or  vicariously,  over  a  greater  or  less  portion  of  the  lungs 
and  stomach.  Sometimes  they  exist  simultaneously  in  the  super- 
ficial cervical  plexus,  and  extend  along  the  tract  of  the  branches 
supplied  by  this  to  the  anterior  parts  of  the  thorax ;  still  more 
frequently,  at  the  very  time  they  are  felt  most  severely  in  the 
heart,  they  shoot  with  corresponding  violence  along  the  nerves  of 
the  axillary  plexus,  and  more  particularly  along  the  brachial  nerve 
to  the  elbow,  and  sometimes  as  far  as  the  fingers.  When  this  is 
the  case,  the  affection  is  confounded  with  a  nervous  disease  which, 
during  the  last  twenty  years,  has  been  the  object  of  much  discus- 
sion, and  seems  to  me  only  a  variety  of  the  neuralgia  in  question. 


75G  ANGINA    PECTORIS. 

This  disease  is  the  angina  pectoris,  which  is  very  remarkable 
and  very  distressing,  when  it  exists  in  a  high  degree,  but  which 
is  far  from  possessing  the  degree  of  severity  attributed  to  it  by 
many  authors.  It  was  taken  notice  of,  as  a  separate  disorder,  for 
the  first  time,  about  the  middle  of  the  last  century  ;  and  has  since 
been  much  noticed  by  physicians,  especially  the  English,  who  have 
considered  it  as  essentially  dependent  on  an  organic  affection  of 
the  heart.  I  shall  discuss  the  correctness  of  this  opinion  after  I 
have  given  an  account  of  the  symptoms  characterizing  this  dis- 
order. 

The  Angina  Pectoris  is  a  spasmodic  affection  which  returns  in 
paroxysms,  after  longer  or  shorter  intervals.  The  attack  com- 
mences with  a  sense  of  pain,  pressure,  or  constriction  in  the  car- 
diac region,  or  at  the  end  of  the  sternum.  There  is  at  the  same 
time  a  numbness,  occasionally  attended  with  pain  in  the  left  arm  ; 
rarely  in  both  arms  or  in  one  half  the  body  ;  more  rarely  still  in 
the  right  arm  only  ;  and  sometimes  in  all  the  limbs.  The  painful 
sensation  is  particularly  felt  on  the  inner  side  of  the  arm,  as  low 
as  the  elbow  ;  and  sometimes,  as  already  mentioned,  it  shoots  still 
further  down.  It  is  not  unusual  for-  the  patient  to  suffer,  at  the 
same  time,  from  pains  over  the  fore  part  of  the  left  chest ;  and  in 
the  female  these  sometimes  so  affect  the  mamma  that  the  slight- 
est pressure  becomes  painful.  Sometimes,  particularly  when  the 
paroxysm  is  severe  but  short,  the  patient  feels  as  if  the  same 
parts  were  pierced  by  iron  nails  or  the  claws  of  an  animal.  There 
are  also  pains  in  different  pojnts  of  the  chest,  dyspnoea,  (in  ex- 
treme cases  suffocative  orthopncea,)  violent  palpitations,  conges- 
tion of  blood  in  the  head,  and  sometimes  syncope  or  convulsions. 
When  the  attack  is  over,  the  patient  merely  retains  a  slight  feeling 
of  these  various  symptoms,  particularly  the  numbness  of  the  limbs, 
the  left  more  especially.  Drs.  Heberden  and  Parry  concluded, 
from  some  cases  witnessed  by  themselves,  that  angina  pectoris 
depended  on  ossification  of  the  coronary  arteries  of  the  heart  ;* 
an  opinion  in  which  they  have  been  followed  by  Burns  and 
Kreysig.  This  opinion  has  not  been  confirmed  by. subsequent 
observation ;  nevertheless  the  greater  number  of  physicians, 
particularly  in  England,  Germany,  and  Italy,  have  still  retained 
the  belief  that  the  disease  in  question  is  always  the  effect  of  some 
organic  affection  .of  the  heart,  that  this  affection  is  one  of  great 
severity — and  that  most  of  the  patients  that  are  attacked  with  it. 
die  suddenly.     These  notions  are  far  from  being  correct. 

Angina  pectoris,  in  .  a  slight  or  middling  degree,  is  extremely 
common,   and   exists  very  frequently  in    persons    who    have    no 

*  Medical  Trans.   Vol.  II.  p.  59.  Vol.  III.  p.  I.     Inquiry  into   the  Symptoms 

and  Cause  oft  he  Syncope  Anginosa.     Bath,  1800 Author      Tins  is  a  mistake 

Dr.  Heberden  did  not  so  consider  it. —  Transl. 


ANGINA    PECTORIS. 


757 


organic  affection  of  the  heart  or  large  vessels.      I  have  known 
many  individuals  who  had   suffered  a   few  very  severe  but  short 
attacks  of  it,  and  had  no  further  return  of    it.     I  am  even  of 
opinion  that  the  prevalent  type  of  disease  influences  its  develop- 
ment, as  I  have  some  years  met  with  it  frequently,  and  hardly  at 
all  in  others.      On  the  other  hand,  it  is  certainly   true   that  this 
affection  frequently  coincides  with  organic  diseases  of  the  heart ; 
but  nothing  proves  even  then  that  it  depends  upon  such  diseases, 
inasmuch  as  they  are  of  various  kinds,  and  as  the  angina  exists 
without  any  of  them.     I  have  examined  several  subjects  who  had 
labored  under  this  disease,  and  in  whom  there  co-existed  either 
hypertrophy  or  dilatation  of  the  heart ;  and  in  none  of  these  did 
I  find  the  coronary  arteries  ossified.     One  of  these  died  suddenly 
during  an  attack  of  angina  ;  and  such  a  result  need  not  surprise 
us,  when  so  severe  a  nervous  affection  co-exists  (as  in  this  case) 
with  extensive  hypertrophy.      Dr.  Desportes,  in  a  dissertation 
published  some  years  since,*  has  stated  opinions  very  analogous 
to  mine  respecting  the  nature  and  seat  of  this  affection  :  he  con- 
siders its  site  to  be  in  the  pneumo-gastric  nerve.     I  conceive  that 
the  site  of  the  disorder  may  vary,  according  to  circumstances. 
For  instance,  when  there  exists,  at  the  same  time,  pain  in  the 
heart  and  lungs,  we  may  presume  that  the  affection  is  principally 
seated  in  the  pneumo-gastric ;  on  the  other  hand,  when  there  is 
simply  a  sense  of  stricture  of  the  heart,  without  pulmonary  pain, 
or  much  difficulty  of  breathing,  we  may  consider  its  site  to  be  in 
the  nervous  filaments  which  the  heart  receives  from  the  grand 
sympathetic.     Other  nerves  are  also  simultaneously  affected,  either 
by  sympathy,  or  from   direct  anastomosis ;    for  example, — the 
branches  of  the  brachial  plexus,  particularly  the  cubital,  are  al- 
most always  so ;  the  anterior  thoracic  originating  in  the  super- 
ficial cervical  plexus,  are  also  frequently  affected  ;  and  this  is  also 
sometimes  the  case  with  the  branches  derived  from  the  lumbar 
and  sacral  plexuses,  as  we  find  the  thigh  and  leg  now  and  then 
participating  in  the  pain  and  numbness.     I  have  even  seen  the 
affection  confined  to  the  right  side  of  the  thorax.     In  this  case 
the  pain  and  numbness  extended  to  the  arm,  thigh,  and  spermatic 
cord  of  the  same  side,  and  the  testicle  became  swollen  during  the 
paroxysms.     There  was  scarcely  any  pain  in  the  region  of  the 
heart ;  but  the  attacks  were  attended  by  severe  palpitation,  with- 
out any  sign  of  organic  lesion  of  the  heart.     The  general  character 
of  the    symptoms  of    the  angina  pectoris    further   confirms,  by 
analogy,  the  correctness  of  the  opinion  here  advocated ;  sintfe  we 
know  the  neuralgias  of  the  most  unequivocal   kind,  for  example, 
the  sciatica  and  tic  douloureux,  give  rise  to  the  same  kind  and 
variety  of  effects  as  it  does, — namely,  acute  pain,  painful  torpor, 

'   Ue  l'Angine  de  poi trine,  8vo.  Paris,  1813. 


758  *  ANGINA    PECTORIS. 

simple  numbness  along  the  tract  of  the  nerve,  and,  sometimes, 
spasm  or  sub-inflammatory  swelling  of  the  parts  to  which  it  is 
distributed.* 

*  In  another  place  (Cyclopaedia  of  Pr act.  Med.  vol.  i.)  I  have  entered  fully  into 
the  consideration  of  the  history  of  the  various  congenerous  affections  which 
have  been  long  classed  under  the  name  of  Jlngina Pectoris.  Referring  to  this, 
then,  for  more  precise  information,  I  must  content  myself  with  giving  here  a  few 
observations  which  bear  most  closely  on  the  more  important  statements  in  the 
text.  Some  of  the  most  remarkable  differences  observed  in  cases  of  angina 
pectoris  have  reference  to  the  physical  condition  of  the  parts  immediately  af- 
fected in  the  paroxysm ;  others  to  the  state  of  the  general  system  with  which 
the  local  affection  is  connected.  In  one  class  of  cases  there  exists  great  structural 
disease  of  the  heart  and  aorta  ;  in  another  class  there  exists  either  no  structural 
disease,  or  none  that  can  be  detected.  The  former  class  of  cases  may  there- 
fore be  termed  organic  angina  ;  the  latter,  functional  angina.  Each  of  these  clas- 
ses may  be  subdivided  according  as  the  affection  of  the  heart  and  »>rta  exists  un- 
complicated with  other  diseases  of  a  general  or  local  kind,  or  co-exists  with  some 
such  disease  or  diseases  on  which  it  is  more  or  less  dependent.  1.  The  cases 
th?t  come  under  the  first  subdivision  of  organic  angina  are  few  in  number. 
They  are  those  in  which  the  anginous  paroxysms  seem  to  be  the  direct  conse- 
quence of  organic  disease  of  the  heart  occurring  in  persons  otherwise  healthy. 
Cases  of  this  kind  are  seldom  very  well  marked,  the  anginous  symptoms  being 
either  feebly  manifested,  or  overpowered  by  the  greater  intensity  of  the  more 
ordinary  symptoms  of  heart-disease.  These  maybe  considered,  in  one  respect, 
as  the  worst  cases  of  angina,  inasmuch  as  they  hold  out  little  prospect  of  cure  or 
even  of  alleviation.  2.  Under  the  next  subdivision  of  organic  angina,  I  would 
include  the  greater  number  of  the  best  marked  and  more  severe  cases  of  this  dis- 
ease. In  these,  along  with  the  organic  affection  of  the  heart  or  vessels,  or  both, 
(probably  not  very  great,  or,  at  least,  marked  rather  by  the  paroxysm  of  angina 
than  by  the  general  symptoms  of  diseased  heart,)  we  have  some  obvious  general 
disorder  of  the  system.  In  cases  of  this  kind,  the  organic  disease  of  the  heart 
and  aorta  seems  often  to  be  a  consequence  of  the  co-existing  disorder ;  if 
not  a  consequence,  it  is  always  greatly  aggravated  by  its  presence ;  and 
hence  the  most  successful  medical  treatment  of  the  angina  is  that  which  has 
direct  reference  to  the  concomitant  disorder.  3.  I  consider  cases  in  which  the 
organic  deviation  is  so  slight  as  to  be  hardly  discoverable,  as  constituting  the 
greater  number  of  those  usually  viewed  by  practitioners  as  examples  of  pure 
functional  or  nervous  angina.  It  is  obvious  that  in  extreme  strictness  of  lan- 
guage they  are  not  entitled  to  this  name  :  yet  if  the  deviation  is  only  so  slight  as 
to  constitute  mere  feebleness.,  (and  it  is  often  nothing  more,)  they  are  probably  as 
well  entitled  to  the  name  as  most  other  diseases  commonly  denominated  ner- 
vous. But  it  must  be  admitted  that  in  persons  possessing  the  best  proportioned 
hearts,  and  in  which  no  deviation  whatever  from  the  normal  structure  can  be 
detected  either  during  life  or  after  death,  there-may  and  do  occur  paroxysms  of 
angina.  The  proportion  of  such  cases  is  however,  very  small  under  any  circum- 
stances in  a  state  of  uncomplication  with  other  diseases;  and  I  look  upon  them 
rather  as  of  possible  occurrence  than  as  having  certainly  met  with  them  in  prac- 
tice. Conjoined,  however,  with  some  other  disorder,  as  in  the  next  cjass  of  cases, 
we  conceive  they  are  by  no  means  rare.  4.  Under  the  head  of  complex  or  sympa- 
thetic functional  angina,  I  must  comprehend  a  large  class  of  cases  ;  and  for  the 
reasons  stated  in  the  last  paragraph,  although  not  strictly  philosophical,  I  would, 
for  practical  purposes  include,  under  the  present  division  all  the  cases  of  ner- 
vous angina  complicated  with  other  diseases,  whether  the  organs  of  the  cirCtt- 
lation^are  perfectly  sound  and  well  proportioned,  or  only  deviating  in  a  very 
slight  degree  from  this  state  of  integrity.  Under  this  head  are  comprehended  a 
very  considerable  proportion  of  the  cases  met  with  in  practice,  and  not  a  few 
of  those  which  present  symptoms  of  the  greatest  severity  in  the  paroxysm. 

The  following  tables  of  the  statistical  and  other  results  derived  from  the  ex- 
amination of  the  more  authentic  published  records  of  angina,  arc  deserving  the 
reader's  attention.     They  are  extracted  from  the  same  article. 


ANGINA    PECTORIS. 


759 


Treatment. — The  means  which  I  have  found  most  successful 
in  relieving  neuralgia  of  the  heart,  whether  existing  in  so  violent 

Results  relative  to  the  scz  of  the  patients. 

Total  number  of  cases  examined        .  88 

Of  these  were,  men 80 

women        ........     8 

Results  relative  to  the  age  of  the  patients. 
Total  number  whose  ages  are  recorded      .         •         •         •         •  *     84 

Of  these  were,  above  fifty  .         •         •         •         •         •         -72 

under  fifty  •         •         •         •         •         •  12 

Results  relative  to  the  event  of  the  cases  generally. 

Total  number  of  patients,  the  event  of  whose  cases  is  recorded         .  64 

Of  these  there  died  (almost  all  suddenly)  .         .         .         .49 

Were  relieved  or  recovered 15 

Results  relative  to  the  event  of  the  cases  as  regards  sex. 

Total  number  of  fatal  cases        . 41) 

Of  these  were,  men  ........  47 

women        . 2 

Total  number  of  cases  cured  or  relieved  15 

Of  these  were  men 11 

women       .........     4 

Results  relative  to  the  existence  of  organic  disease  in  general. 

Total  number  of  cases  of  which  dissections  are  given       ...  45 

Of  this  number  there  was  no  organic  disease  (except  obesity)  in     4 

Organic  disease  of  the  liver  only,  in  .         .         .2 

Organic  disease  of  the  heart  or  great  vessels,  in     .         .  39 

Results  relative  to  the  nature  of  the  organic  affections  of  the  heart  and  great  vessels. 
Total  number  of  cases  in  which  there  was  organic  disease  in  the  heart 

or  vessels     .......-••  39 

Of  this  number  there  was  organic  disease  of  the  heart  alone,  in  10 

Organic  disease  of  the  aorta  alone,  in  .         .         .3 

Organic  disease  of  the  coronary  arteries  alone,  in  .     1 

Ossification  or  cartilaginous  degeneration  of  the  coro- 
nary arteries  in  .         .         .         .         •         ■         •         .16 

Ossification  or  other  disease  of  the  valves  in  .         .  16 

Disease  of  the  aorta  (ossification,  or  dilatation,  or  both)  in  24 

Preternatural  softness  of  the  heart,  in     .         .         .         .12 

Of  the  intimate  nature  of  the  pain  in' the  paroxysm  of  angina  we  know  nothing  ; 
but  we  know  no  more  of  the  nature  of  any  pain.  All  that  wc  can  propound  con- 
cerning it  is  a  relation  of  the  events  which  seem  to  lead  to  it,  and  the  condition  of 
the  parts  in  which  it  occurs,  at  the  time  of  its  occurrence.  We  know  that  the 
pain  is  not  of  that  kind  which  arises  from  inflammation,  or  ulceration,  or  any 
other  fixed  physical  alteration  of  a  part.  All  the  circumstances  attending  it 
prove  it  to  be  of  that  kind  which  occurs  in  cramp  or  spasm,  or  from  pressure,  or 
in  ill.;  class  of  cases  termed  neuralgic,  in  which  the  painful  sensation  is  the  re- 
sult of  some  unknown  temporary  condition  of  the  nerves  of  the  part,  not  manifest- 
ed by  any  physical  alteration  of  them  discoverable  by  our  senses.  We  have  suf- 
ficient evidence  that  such  a  morbid  condition  of  the  nerves  may  be  produce  d  in 
a  heart  in  all  other  respects  sound  ;  and  when  it  takes  place  in  a  heart  manifest- 
ly diseased  in  its  structure,  we  must  consider  the  structural  lesions  merely  as 
predisposing  and  exciting  causes  of  the  pain.  That  the  structural  lesions  are 
not  the  immediate  and  necessary  source  of  the  pain,  is  sufficiently  proved  by  its 
intermittin"  character,  and  the  perfect  ease  in  the  intervals,  when  the  structural 
lesion  is  precisely  the  same  as  during  the  paroxysm.  The  anatomical  structure, 
the  peculiar  action  and  functions  of  the  heart  and  annexed  great  vessels,  will 
sufficiently  explain  all  the  modifications  of  the  pain  and  other  phenomena  ob- 
served in  the  anginous  paroxysm.  The  radiation  of  the  pain  to  a  distance  from 
the  primary  and  principal  site  of  it  is  only  in  conformity  with  what  is  observed 
in  all  other  painful  affections.  Stone  in  the  bladder  produces  pain  in  the  glans 
penis;  calculus  in  the  ureter,  pain  in  the  abdominal  walls  ;  inflammation  of  the 
cartilages  of  the  hip-joint,  pain  in  the  knee  ;  and  what  is  perhaps  a  still  more  ap- 


760  ANGINA    PECTORIS. 

a  degree  as  to  be  named  angina  pectoris,  or  only  under  the  form 
of  slight  pains  confined  to  the  heart,  are  those  formerly  men- 
tioned in  the  case  of  neuralgia  of  the  lungs,  and  especially  the 
magnet.  This  I  use  in  the  following  manner : — I  apply  two 
strongly  magnetized  steel  plates,  of  a  line  in  thickness,  of  an  oval 
shape,  and  bent  so  as  to  fit  the  part, — one  to  the  left  cardiac 
region,  and  the  other  exactly  opposite,  on  the  back,  in  such  a 
manner  that  the  magnetic  current  shall  traverse  the  affected 
part.  This  method  is  not  infallible,  any  more  than  others  em- 
ployed in  nervous  cases;  but  I  must  say  that  it  has  succeeded 
better  in  my  hands,  in  the  case  of  angina,  than  any  other,  as  well 
in  relieving  the  paroxysm  as  in  keeping  it  off. 

Magnetism  was,  perhaps,  too  much  cried  up  by  some  medical 
men  in  the  last  century ;  but  I  am  of  opinion  that  it  is  too  much 
neglected  at  present.  That  it  acts  on  the  animal  system,  is  suf- 
ficiently proved  by  the  fact  of  its  giving  rise  not  only  to  very 
obvious  general  effects,  but  even  to  local  ones.  In  the  case  in 
question,  after  a  certain  time  it  most  commonly  produces  an 
eruption  of  small  pimples,  which  are  sometimes  so  painful  as  to 
oblige  us  to  interrupt  the  process  for  some  days.  This  effect 
cannot  be  attributed  to  the  action  of  the  oxydized  plates  on  the 
skin,  as  the  eruption  almost  always  takes  place  under  the  anterior 
one ;  and  I  have  observed  similar  results  from  plates  applied  over 
the  abdomen  and  loins.  By  means  of  these  plates  (applied  to 
the  epigastrium  and  spine)  I  stopped,  at  once,  a  hiccup  which 
had  lasted  three  years.  At  the  end  of  six  months,  the  patient 
having  one  morning  neglected  to  put  on  the  plates,  the  hiccup 
returned,  but  was  removed  upon  their  being  replaced.  In  anoth- 
er case,  in  a  patient  affected  with  imperfect  paraplegia,  without 
any  sign  of  structural  lesion  of  the  spine,  and  for  which  moxa 
had  been  used  without  success,  I  inserted,  to  the  depth  of  half  an 
inch,  a  needle  near  the  vertebral  column,  and  another  into  the 
thigh,  near  the  external  popliteal  nerve,  and  connected  these  by 
means  of  magnetized  rods  ;  and  at  the  very  instant  of  contact, 
there  occurred  an  involuntary  dejection,  which  had  never  pre- 
viously happened  to  the  patient.  In  the  angina,  when  the  magnet 
gives  but  little  relief  simply,  this  is  sometimes  found  to  be  increased 
on  applying  a  small  blister  under  the  anterior  plate. 

During  the  paroxysm,  if  the.  oppression  is  considerable,  we 
must  bleed  the  patient,  if  he  is  at  all  plethoric.  Leeches  applied 
to  the  epigastrium  or  cardiac  region  sometimes  give  more  relief 

propriate  illustration,  irritation  at  the  origin  of  nerves  in  general,  frequently 
manifests  itself  only  liy  pain  at  their  extremities.  In  a  word,  tlic  pain,  in  the 
paroxysm  ol  angina,  may  rise  from  neuralgia,  from  spasm,  from  over-disteotion  ; 
and  the  other  principal  phenomena  may  all,  I  think,  he  explained  by  the  de- 
rangements of  the  functions  of  the  heart,  considered  as  a  muscular  organ  charged 
with  the  office  of  circulating  the  mass  of  blood.—  Transl. 


ANGINA    PECTORIS.  '61 

than  venesection  ;  but  sometimes  their  application  is  impracticable 
from  the  extreme  agitation  of  the  patient.  Derivatives  are  also 
beneficial,  particularly  sinapisms  to  the  lower  extremities  and  blis- 
ters to  the  fore  part  of  the  chest ;  as  are  also  antispasmodic  med- 
icines, with  the  infusion  of  cherry-laurel  or  digitalis,  and  also  the 
fetid  gums.  A  mild  regimen,  with  the  use  of  the  tepid  or  cold 
bath,  according  to  the  season,  are  among  the  best  means  for  pre- 
venting a  return  of  the  paroxysm.* 

*  As  in  the  cases  of  many  other  of  the  diseases  described  in  this  work,  the 
treatment  recommended  in  angina  is  meager  and  indiscriminating.  My  space 
will  not  here  allow  me  to  supply  the  deficiency,  and  I  must  content  myself  with 
one  or  two  general  observations  on  the  principles  which  ought  to  regulate  our 
practice,  referring  for  details  to  the  article  quoted  in  the  last  note.  Like  that  of 
all  diseases  of  an  intermitting  or  paroxysmal  character,  the  treatment  of  angina 
requires  to  be  considered  in  two  very  distinct  points  of  view — in  the  paroxysm, 
and  in  the  interval. — I.  As  there  can  be  no  doubt  that  the  paroxysms  of  angina 
arise  under  very  different  conditions  of  the  system,  and  as  they  differ  very  mate- 
rially in  their  immediate  causes,  or  in  the  condition  of  the  organs  immediately 
affected,  all  rational  treatment  must  have  regard  to  these  circumstances  in  indi- 
vidual cases,  as  far  as  they  are  known  or  can  be  ascertained.  Painful  muscular 
spasm,  or  simple  neuralgia  of  the  heart  and  aorta,  whether  ultimately  depending 
on  organic  disease  of  the  parts  or  not,  may  recognize  very  opposite  exciting  cau- 
ses, and  may,  therefore,  be  best  relieved  by  different  means.  In  one  case,  for 
instance,  the  patient  may  be  strong  and  robust,  and  his  whole  vascular  system 
overloaded  ;  in  another,  he  may  be  the  victim  of  long  previous  disease,  with  a 
deficiency  both  of  blood  and  constitutional  power;  while,  in  a  third,  the  system 
may  be  comparatively  healthy,  with  or  without  local  disease  of  the  organs  of  cir- 
cnlation,  and  with  or  without  great  nervousness  of  temperament.  In  all  these 
varieties  the  treatment  will  require  modification  to  suit  it  to  the  individual  case. 
When  previously  known,  such  circumstances  must,  therefore,  be  kept  in  mind 
by  the  practitioner  ;  when  not  known,  an  attempt  must  be  made  to  ascertain 
them  before  he  prescribes  for  the  patient.  Inattention  to  circumstances  of  this 
kind  has  often  rendered  the  treatment  much  less  effective  than  it  might  have 
been,  or  has  rendered  it  decidedly  injurious.  It  must  be  confessed,  however, 
that  in  many  cases  it  is  extremely  difficult,  if  not  impossible,  to  come  to  any 
certain  judgment  as  to  the  actual  pathological  condition  of  the  affected  parts, 
or  even  of  the  system  generally,  during  the  paroxysm.  A  previous  knowledge 
of  the  patient,  and,  yet  more,  the  having  had  opportunities  of  studying  the 
case  in  former  attacks,  will  here  be  of  the  greatest  importance.— II.  If  it  is 
of  consequence  for  the  practitioner  to  be  acquainted  with  the  precise  nature  of 
the  case  before  him  to  enable  him  to  prescribe  successfully  or  even  safely  in  the 
paroxysm  of  angina,  it  is  much  more  important  that  he  should  have  this 
knowledge  to  direct  his  treatment  in  the  interval.  In  many  cases,  no  doubt,  it 
is  quite  impossible  to  ascertain  the  intimate  character  of  the  affection  dur- 
ing the  paroxysm;  and  in  a  certain  proportion  of  these,  the  knowledge,  if 
attainable,  would  be  of  little  use.  We  should  still  be  reduced  to  the  necessity 
of  applying  the  same  limited  stock  of  means  without  any  very  inspiring  confi- 
dence of  a°beneficial  result.  Circumstances,  however,  are  very  different  in  the 
interval.  Here,  an  accurate  acquaintance  with  the  nature  of  the  individual 
is  indispensably  necessary  to  enable  us   to   institute  treatment  that  holds 

msrely 


called  on  to  treat  a  case  of  angina,  will  be  to  make  himself  acquainted  with  its 
individual  character.  Beginning  with  the  early  history  of  the  disease,  he  will 
trace  it  to  its  present  stage,  and  will  endeavor,  from  the  narrative  of  the  pa- 
tienl  and  from  the  observation  of  the  whole  phenomena  presented  to  him,  to  form 
a  clear  judgment  respecting  the  local  condition  of  the  organs  in  which  the  char- 
acteristic symptoms  have  their  site  ;    and  the  state  of  all  the  other   parts  of  the 

96 


762  PALPITATION    OF    THE    HEART. 


Sect.  II. — Of  Palpitation  of  the  Heart. 

In  a  former  part  of  this  work  I  took  some  notice  of  palpita- 
tions in  general ;  I  shall  here  consider  those  of  a  purely  nervous 

system,  which  can  in  any  way  influence  these  :  in  other  words,  he  must  endea- 
vor to  ascertain  the  species  or  variety  of  angina,  according  to  the  distinction 
formerly  pointed  out.  Are  the  paroxysms  dependent  on  some  structural  lesion- 
of  the  heart  and  great  vessels,  or  are  these  organs  in  their  original  soundness  ? 
If  there  is  any  deviation  from  the  sound  condition  of  these  organs,  what  is  the 
nature  of  this  deviation  ?  Does  structural  lesion  exist  or  not  ?  or,  if  existing, 
can  it  be  detected  or  not  ?  What  is  the  actual  physical  condition  of  the  heart  ? 
Are  its  walls  thick  or  thin  ?  Are  its  cavities  large  or  small  ?  What  is  the  state  of 
the  general  health  ?  Is  it  such  as  injuriously  to  influence  the  recurrence  of  the 
paroxysms  in  any  way,  or  to  aggravate  their  severity?  If  thus  injuriously  influ- 
encing the  local  disease  of  the  heart  and  great  vessels,  is  it  of  a  kind  to  be 
remedied  or  mitigated  by  medical  treatment?  These  queries  comprehend  most 
of  the  subjects  of  inquiry  which  the  practitioner  who  proceeds  to  treat  a  oase  of 
angina  must  keep  in  view;  and  although  it  will  sometimes  be  impossible  to 
obtain  precise  information  on  every  point,  yet  this  will  be  practicable,  in  the 
greater  number  of  cases,  by  care  and  attention  and  by  the  employment  of  the 
improved  methods  of  investigating  thoracic  diseases  furnished  by  auscultation. 
This  latter  method  of  exploration  will,  in  a  more  particular  manner,  aid  our 
recognition  of  the  physical  condition  of  the  heart;  and  enables  us,  in  a  great 
number  of  cases,  to  determine  the  presence  or  absence  of  organic  disease  in 
that  organ.  This  precise  knowledge  is,  no  doubt,  important  in  assisting  us  to 
regulate  our  practice  with  the  best  advantage  to  the  patient :  but  it  is  infinitely 
more  so  in  enabling  us  to  form  an  accurate  prognosis  respecting  the  event  of  the 
case.  If  the  attacks  recognize  great  structural  lesion  of  the  heart  or  aorta  for 
their  cause,  we  can  only  expect  to  mitigate  the  severity  of  the  paroxysms,  or  to 
effect  their  temporary  removal.  If  there  exists  no  structural  lesion  of  a  fatal 
kind,  although  the  organs  may  not  be  of  the  soundest  proportions,  it  is  often 
practicable,  not  merely  to  mitigate  or  remove  the  paroxysms,  but  by  great  and 
constant  vigilance  on  the  part  of  the  patient  in  avoiding  the  exciting  causes,  to 
prevent  their  recurrence  altogether.  When  the  disease  is  purely  one  of  func- 
tional disorder,  a  much  more  perfect  and  permanent  cure  may  be  expected.  In 
all  these  cases,  however,  the  general  character  of  the  treatment  will  not  greatly 
vary.  An  organic  lesion  of  the  heart,  even  of  an  incurable  kind,  can  only  be 
viewed,  in  relation  to  the  treatment,  as  a  predisposing  cause  of  the  attacks,  just 
as  a  heart  that  is  naturally  feeble  or  morbidly  irritable  is  so  :  and  it  is  only  in 
rare  cases  that  the  organic  lesion  induces  the  paroxysm  without  the  aid  of  obvi- 
ous exciting  causes.  No  doubt,  exciting  causes  of  much  feebler  kind  will  suffice  ; 
but  the  very  necessity  of  such  causes  at  all  to  produce  the  effect,  brings  the 
case,  as  far  as  concerns  the  prevention  of  the  paroxysms,  under  the  same  catego- 
ry as  to  treatment  as  the  purely  sympathetic  or  nervous  angina.  In  the  case  of 
organic  disease,  however,  our  expectations  of  benefit  from  treatment,  and  the 
actual  results,  become  wonderfully  less.  Now,  indeed,  we  fight  not  for  victory, 
but  merely  to  keep  the  enemy  at  bay.  We,  however,  use  the  same  weapons  : 
and  if  we  do  not  strive  with  the  same  enthusiasm,  we  must,  at  least,  be  vigilant 
and  active  ;  and  we  shall  often  be  rewarded  with  a  degree  of  success  that  we 
scarcely  dared  to  hope  for  at  the  commencement  of  our  treatment. 

LITERATURE  OF  ANGINA  PECTORIS. 

1740.  Crellius  (J.  F.)  De  arteria  coronaria  instar  ossis  indurata  observatio  (Haller 

Diss,  ad  Morb.  ii.  563.)    Wittemb. 
1768.  Rougnon  (N.  F.)  Lettre  a  M.  Lorry  sur  une  maladie  nouvelle.  Besancon. 

8vo. 
1778.  Eisner  (C.  F.)  Abhandlung  euber  die  Brustbraiinc.     Konigs.  8vo. 
1782.  Gruner  (C.  G.)  Spicilegium  ad  Angin.  Pect.  (Diss.  Doeringl.)  Gen. 


PALPITATION    OF    THE    HEART. 


763 


kind,  that  is,  such  as  exist  without  any  organic  lesion.  These 
are  frequently  much  more  troublesome  than  the  others.  Far 
from  being  removed  by  the  most  complete  repose,  they  are  in 
general  felt  to  be  most  distressing  during  the  first  part  of  the 
night.  It  frequently  happens  that  they  prevent  sleep  for  several 
hours,  while  a  moderate  degree  of  exercise,  proportioned  to  the 
patient's  strength,  removes  or  at  least  alleviates  the  distressing 
feeling  of  them.  The  purely  nervous  palpitations  consist  in  an 
increase  of  the  impulse,  sound,  and  particularly  of  the  frequency 
of  the  heart's  pulsations.  A  feeling  of  internal  agitation,  par- 
ticularly in  the  head  and  abdomen,  always  accompanies  them ; 
also  a  limpid  watery  condition  of  the  urine.  The  duration  of 
palpitations  of  this  kind  is  very  variable  :  they  may  be  momen- 
tarily excited  by  mental  emotion  ;  while,  at  other  times,  they 
seem  to  originate  without  any  obvious  cause,  and  continue  for 
several  years,  especially  in  young  persons  who  are  at  the  same 

1787.  Schaeffer.  Diss,  de  Angina  Pectoris.     (Docring  I.)   Goett. 

1788.  Tode  (J.  C.)  De  Inflamm.  Pect  Chron.  Angina  Pectoris.     Harm.  8vo. 
1791.  Butter  (W.,  M.D.)  Treat,  on  the  dis.  commonly  called  Angina  Pectoris. 

Lond. 
1791.  Hartmann.  Diss,  de  Angina  Pectoris.     France. 
1793.  Schmidt.  Diss,  de  Angina  Pectoris.     Goett. 

1799.  Parry  (C.  H.,  M.D.)  An  Inq.  into  the  symp.  and  caus.  of  Syncope  Angi- 

nosa.  Bath. 

1800.  Hesse.  Specimen  de  Angina  Pectoris.     Halle. 
1802.  Sluis.  Diss,  de  Sternodynia  Syncopali.     Groen. 

1804.  Hume  (Gustavus)  Obs.  on  Angina  Pectoris,  Gout,  &c.  Dull.  8vo. 
1806.  Jahn  (F.)  Uuber  die  Syncope  Anginosa  (Hufeland's  Journ.)  Berl.  8vo. 
1806.  Baumes  (J.  B.  T.)  Traite  Element,  de  Nosol.     Par.  8vo. 

1810.  Brera(L.  V.)  Delia  Stenocardia.     Verona.  4to. 

1811.  Desportes  (E.  H.)  Traite  de  l'Angine  de  Poitrine.     Par.  8vo. 

1812.  Millot.     Diss,  sur  l'Angine  de  Poitrine.     Par. 

1812.  Renauldin.     Diet,  des  Sc.  Med.     (Art.  Angina,  t.  ii.)  Par. 
1812    Chrzezonowicz.     Diss,  de  Angore  Pectoris.     Vilnce. 

1813.  Zechinelli  (G.  M.)  Sull'Angina  di  Petto  et  sulle  morte  repentine  conside- 

razioni.     Padova.      8vo. 
1813.  Bogart  (Henry)  An  inaug.  Dissert,  on  Angina  Pectoris.     JVeio-  York.  Svo. 
1815.  Jurine  (L.,  M.D.)  Memoire  sur  l'Angine  de  Poitrine.     Par.  8vo. 
1817    Zechinelli,  (G.  M.)  Sopra  una  mallattia  di  Seneca  ii  filosofo.     Pad.  8vo. 

1818.  Blackall  (John,  M.D.)    Observations  on  Dropsies :  with  an  Appendix  con- 

taining cases  of  Angina  Pectoris.  Lond.  8vo.  3d  edit. 

1819.  Black,  (S.,  M.D.)  Clinical  and  Pathological  Reports.     Mwry.Svo. 

L821    Raige-Delorme.     Diet,  de  Med.  (Art.  Engine  de  Poitrine.)  t.  2.  Par.  Svo. 
L821     Pine!  et  Bricheteau.  Diet,  de  Sc.  Med.  (Art.  Stcrnalgic,)  t.  o2.    Par.  Svo 
1822.  Schramm.     Diss,  de  Angina  Pectoris,  (cum  Tab  acn .)     Lips.  8vo.       ^ 
1824    Hosack  (D.,  M.D.)  Essays  on  various  subjects  of  Med.  JVew  York.  Svo. 
1825'.  Frank  (Jos.)  Prax.  Med.  Univ.  P.  II.  vol.  8      Taurm.  Svo. 
1829    Walker  (F   K    M.D.)  Remarks  on  Angina  Pect.  (Midi.  Journ.  I.)    Wore. 
1829.  Jolly.  Diet,  de  Med.  &.  de  Chir.  Pr.  (Art.  Engine  de  Poitrine)  t.  2.  Par. 

1832    Forbes.  Cyc.  of  Pract.  Med.  (Art.  Angina  Pect.)  vol.  I.  Lond. 
1832    Conland.     Diet,  of  Pract.  Med.  (Art.  Angina  Pectoris.)     Lond.  Svo. 

Ito  Sauvagcs,  Darwin,  Johnstone  E.  and  J.,  Fothergill,  Heberden,  Latham, 
Percival  Waft,  Good,  and  the  various  systematic  writers  on  medicine;  the 
various  Treaties  on  Diseases  of  the  Heart,  and  innumerable  mdiv.dual  cases 
in  journals  and  transactions  of  societies.—  Transl. 


764  PALPITATION    OF    THE    HEART. 

time  both  nervous  and  plethoric. — It  is  commonly  imagined  that 
such  an  habitual  over-action  of  the  heart  as  such  palpitations 
imply,  must  at  length  give  rise  to  hypertrophy  of  this  organ. 
This  is  possible  ;  but  I  must  say  that  I  have  never  seen  any  proof 
of  the  accuracy  of  this  opinion.  On  the  other  hand,  I  am  ac- 
quainted with  individuals  who  have  been  habitually  subject  to 
affections  of  this  kind,  and  who  nevertheless  exhibit  no  positive 
sign  either  of  hypertrophy  or  dilatation.* 

I  formerly  took  some  notice  of  the  signs  which  distinguish 
nervous  palpitation  from  hypertrophy  or  dilatation  of  the  heart : 
I  shall  here  state  them  somewhat  more  precisely.  In  nervous 
palpitation,  the  first  impression  conveyed  by  the  stethoscope  is 
that  the  heart  is  not  enlarged.  The  sound,  though  clear,  is  not 
heard  loudly  over  a  great  extent  of  chest ;  and  the  impulse,  al- 
though appearing  considerable  at  first,  is  really  not  great,  as  it 
never  sensibly  elevates  the  head  of  the  observer.  This  last  sign, 
seems  to  me  the  most  important  and  certain  of  any,  when  taken 
in  conjunction  with  the  frequency  of  the  pulsations.  These  are 
always  quicker  than  natural, — being,  most  frequently,  from 
eighty-four  to  ninety-six  in  the  minute.  Nervous  palpitations 
are  rarely  accompanied  by  any  sign  of  determination  of  blood  to 
the  head  or  chest,  except  in  old  persons. 

The  treatment  of  nervous  palpitations  consists  principally  in 
the  employment  of  bathing — tepid  or  cool  according  to  the  season 
— the  infusion  of  cherry-laurel  and  digitalis.  Bloodletting  ought 
to  be  employed  with  caution,  and  never  unless  the  patient  be 
young  and  plethoric :  it  is  almost  always  injurious  in  such  as 
occur  in  hypochondriacal  and  hysterical  subjects.  The  same 
observation  applies  to  a  too  rigid  diet,  which,  like  bloodletting, 
frequently  increases  the  nervous  agitation. f 

*  This  seems  in  opposition  to  a  statement  formerly  made  in  the  chapter  on 
the  causes  of  diseases  of  the  heart ;  it  may  be,  nevertheless,  and  no  doubt  is, 
quite  true. — (M.  L.) 

t  It  is  very  true  that  in  cases  of  nervous  palpitation,  venesection  is  seldom  of 
any  use,  and  is  often  hurtful.  It  is  not  uncommon  to  see  these  palpitations  occur 
in  cases  where  bleeding  would  be  very  pernicious,  as  in  chlorosis.  In  this  dis- 
ease the  palpitations  may  be  so  violent  and  painful  as  to  lead  to  suspicion  of  a 
hypertrophy  of  the  heart.  If  under  such  a  mistake,  bleeding  be  resorted  to, 
the  palpitations  will  increase.  In  many  other  cases,  venesection  will  have  the 
same  effect.  The  application  merely  of  a  few  leeches  is  often  sufficient  to 
bring  on  these  palpitations,  and  occasion  a  great  degree  of  exhaustion.  The 
stomach  at  the  same  time  suffers,  the  pulse  quickens,  and  an  appearance  of  fever 
ensues.  I  have  known  persons  for  a  long  time  subject  to  palpitations  which 
were  first  brought  on  by  bleeding.  I  have  known  also  cases  of  acute  articular 
rheumatism  treated  by  abundant  emissions  of  blood,  the  consequence  of  which  was 
an  attack  of  palpitations  which  left  no  doubt  as  to  the  cause  of  their  occurrence. 
These  palpitations  declined  in  proportion  as  the  bleedings  were  discontinued 
and  the  patient  recovered  strength.—  Andral. 


SPASM    OF    THE    HEART. 


764 


Sect.  III. —  Of  Spasm  of  the  Heart,  with  the  bellows-sound 
and  purring-thrill. 

I  formerly  showed  that  the  bellows-sound  of  the  heart,  al- 
though frequently  accompanying  an  organic  affection  of  this 
organ,  may  exist  without  this,  and  be  dependent  on  a  simple 
modification  of  the  nervous  influence.  But  even  in  this  case,  it 
is  always  attended  by  symptoms  which  constitute  a  real  state  of 
disease.  It  is,  generally  speaking,  in  hypochondriacs,  particularly 
such  as  are  of  a  sanguine  temperament  and  plethoric,  that  we 
most  frequently  observe  the  bellows-sound.  And,  in  this  case, 
it  almost  always  exists  in  some  of  the  arteries  at  the  same  time : 
frequently  it  passes  from  one  to  the  other.  It  is  sometimes  con- 
tinuous, sometimes  intermittent :  in  the  latter  case,  it  recurs  on 
the  slightest  agitation  of  body  or  mind  experienced  by  the  patient : 
even  the  act  of  breathing  deeply  or  coughing  suffices  to  induce  it. 
The  symptoms  which  accompany  it,  are  the  more  severe  in  pro- 
portion as  the  sound  is  greater,  more  continuous,  and  extending 
to  a  greater  number  of  arteries.  When  it  is  very  constant  and 
distinct,  but  confined  to  the  heart,  there  is  almost  always  more  or 
less  dyspnoea,  with  a  feeling  of  greater  or  less  debility,  so  that 
the  patient  can,  in  many  cases,  hardly  walk.  These  symptoms 
are  still  more  marked,  if  the  purring-thrill  accompanies  the  bel- 
lows-sound. There  is  commonly  but  slight  nervous  agitation, 
particularly  when  the  patient  is  quiet  ;  but  on  attempting  to  walk 
rather  quick,  or  for  any  length  of  time,  he  is  soon  out  of  breath, 
and,  in  the  severer  cases,  the  head  becomes  confused.  When  this 
affection  is  not  connected  with  organic  lesion  of  the  heart,  the 
treatment  ought  to  be  the  same  as  that  of  the  nervous  disorders 
of  the  arteries,  which  I  now  proceed  to  notice. 

Sect.  IV. — Of  Nervous  Affections  of  the  Arteries. 

Neuralgia  of  the  Arteries. — Pains  more  or  less  acute,  continued 
or  intermittent,  sometimes  follow  the  course  of  the  arteries,  and 
appear  to  have  their  site  in  the  nervous  filaments  supplied  to 
these  vessels  by  the  ganglionic  system.  These  pains  are,  in  ge- 
neral, less  acute  than  those  situated  in  the  nerves  derived  from 
the  brain  or  spinal  marrow.  They  are  particularly  prevalent  in 
hypochondriacs  and  hysterical  women. — The  means  formerly  re- 
commended in  the  same  affection  of  the  heart  and  lungs,  are  the 
only  ones  applicable  to  the  present  case.  The  most  efficacious 
is  a  blister  over  the  affected  part,  when  such  an  application  is 
practicable. 

Increased  pulsation  of  the  arteries. — This  phenomenon  fur- 


S66         NERVOUS  AFFECTIONS  OF  THE  ARTERIES. 

nishes  the  best  proof  that  the  arteries  have  an  action  of  their 
own,  independent  of  that  of  the  heart.  It  is  thus  by  no  means 
very  rare  to  find  the  pulsation  of  one  of  the  carotid  or  temporal 
arteries  vastly  greater  than  that  of  the  other.  A  like  difference 
is  still  more  common  in  the  radial  arteries :  it  even  exists  in  the 
state  of  health,  in  most  men,  the  right  pulse  being  almost  always 
stronger  than  the  left.  Does  this  depend  on  the  right  arm  being 
more  exercised  than  the  left  ?  I  have  sometimes  observed,  during 
the  course  of  a  disease,  the  radial  arteries  become  alternately 
stronger  and  weaker ;  or  the  left  become  the  stronger  of  the  two, 
although  the  contrary  had  been  the  case  in  health.  This  morbid 
degree  of  impulse  is  not  at  all  unusual  in  the  aorta,  particularly 
in  the  ventral  portion  of  it.  A  sense  of  fullness  always  attends 
this  augmentation  of  impulse,  the  affected  artery  seeming  to  be 
always  as  full  as  possible,  and  more  than  the  other  parts  of  the 
arterial  system. 

When  this  phenomenon  exists  only  in  a  single  artery  of  a  small 
or  middling  size,  it  is  attended  by  no  obvious  alteration  of  the 
health, — except  in  the  case  where  it  is  occasioned  by  inflamma- 
tion of  the  part  on  which  the  vessel  is  distributed ;  as  when  the 
arteries  of  the  arm  are  excited  by  a  whitlow.  Augmented  im- 
pulse of  the  carotids  usually  accompanies  nervous  affections,  but 
does  not  always  exist  in  subjects  either  threatened  or  affected 
with  apoplexy.  Nervous  palpitations  of  the  heart  are  some- 
times accompanied  by  a  similar  agitation  of  the  whole  arterial 
system,  the  patient  being  sensible  of  the  arterial  action  over  the 
whole  body  ;  and  sometimes  this  is  visible,  even  in  the  smaller 
vessels. 

In  the  case  of  the  aorta,  these  nervous  phenomena  are  always 
conjoined  with  a  more  or  less  painful  affection  of  the  general 
system, — even  when  they  are  confined  to  one  portion  of  this  artery. 
When  seated  on  the  ascending  aorta  they  are  accompanied  with 
some  degree  of  oppression  in  the  breathing,  and  yet  more  with  a 
sense  of  anxiety  and  tendency  to  syncope. — We  recognize  this 
affection  by  the  pulsations  heard  above  the  middle  of  the  sternum, 
being  stronger  and  more  sonorous  than  those  heard  in  the  cardiac 
region, — the  sternum  at  the  same  time  yielding  the  natural  reso- 
nance on  percussion.  The  symptoms  are  nearly  the  same  when 
the  descending  aorta  is  the  part  affected  ;  and  the  affection  is  dis- 
tinguished by  the  pulsations  of  the  heart  appearing  more  audible 
in  the  back,  especially  the  left  side,  near  the  spine,  than  in  the 
region  of  the  heart  itself.  In  this  situation,  indeed,  they  arc 
most  commonly  quite  natural,  both  in  respect  of  sound  and  im- 
pulse :  whilst  in  the  back,  the  sound  of  the  diastole  of  the  arte- 
ries being  confounded  with  that  of  the  ventricles,  makes  this  seem 


SPASM    OF    THE    ARTERIES. 


767 


much  stronger, — the  sound  of  the  auricles  being  at  the  same  time 
less  than  on  the  fore-part  of  the  chest. 

In  the  ventral  aorta,  the  phenomenon  is  much  more  frequent 
still,  and  may  often  induce  the  belief  of  aneurism.  I  have  several 
times  seen  this  error  committed ;  and  it,  in  truth,  is  easily  fallen 
into,  when  the  accumulation  of  gas  into  the  duodenum  or  colon 
stimulates  the  aneurismal  tumor.  I  made  the  mistake  myself  in 
one  case  ;  but  I  have  since  been  enabled  to  distinguish  several 
others  of  the  same  kind  chiefly  by  this  circumstance — that,  in  the 
case  of  aneurism,  we  cannot  by  examination  ascertain  the  natural 
calibre  of  the  artery,  which  we  can  do  in  the  nervous  affection, 
with  the  greatest  ease,  more  especially  by  means  of  the  stetho- 
scope. There  is  no  other  way  of  accounting  for  the  formation 
and  disappearance  of  swellings  of  this  kind,  but  by  the  supposi- 
tion of  air  confined  in  some  manner  within  one  of  the  cells  of  the 
colon.  And  yet  it  is  singular  that  such  swellings  will,  as  I  have 
myself  observed,  last  for  months,  and  then  disappear.  These  are 
the  cases  in  which  practitioners  boast  of  resolving  palpable  ob- 
structions ;  or  else  they  are  tumors  containing  vesicular  worms, 
which,  on  dying,  contract  into  so  small  a  space  as  to  be  no  longer 
perceptible. 

Spasm  of  the  arteries,  with  the  bellows-sound  and  purring- 
thrill. — When  the  bellows-sound  of  the  arteries  exists  only  in 
one  vessel  of  a  small  or  middling  size,  more  particularly  if  it  is 
intermittent,  it  is  connected  merely  with  a  degree  of  nervous  agi- 
tation, often  very  slight,  and  with  a  frequency  of  pulse,  either 
habitual  or  produced  by  the  slightest  exertion.  It  is  especially 
in  young  plethoric  hypochondriacs  that  it  exists  in  this  degree. 
In  this  case  it  is  usually  seated  in  the  subclavians,  more  rarely 
in  the  carotids,  and  more  frequently  in  the  right  than  in  the  left. 
In  rare  cases  it  is  met  with  in  fevers ;  it  is  by  no  means  unusual 
in  disease  of  the  heart :  and  it  is  still  more  common  in  nervous 
palpitations.  When  the  bellows-sound  exists  in  the  aorta,  par- 
ticularly the  ventral  portion  of  it,  there  is. always  a  marked  state 
of  disorder  in  the  nervous  system,  viz.  agitation  and  anxiety, 
faintings  more  or  less  complete,  and  produced  by  the  slightest 
causes  or  even  without  any  obvious  cause  ;  and  an  habitually 
quick  pulse.  When  both  carotids  are  affected  at  the  same  time, 
and  there  co-exists  the  purring-thrill,  the  same  symptoms  are 
present,  but  in  a  somewhat  less  degree.  In  both  cases,  we  can 
almost  always  excite  the  bellows-sound  artificially  in  the  crural 
and  brachial  arteries,  in  the  manner  formerly  pointed  out.  When 
the  phenomenon  is  present  at  the  same  time  in  the  heart  and 
aorta,  and  in  the  carotid,  subclavian,  brachial,  and  crural  ar- 
teries, there  is  extreme  anxiety,  oppressed  breathing,  frequent 
pulse,  and  sometimes   a  feeling  of  internal  heat,  without  any 


768  SPASM    OF    THE    ARTERIES. 

other  sign  of  formal  fever.  This  condition  of  the  system  is  al- 
ways important,  and  may,  I  conceive,  of  itself  produce  death. 
When  the  bellows-sound  is  very  intense  and  exists  in  a  great 
many  arteries  at  the  same  time,  the  purring-thrill  is  commonly 
perceptible  in  some.  This  phenomenon,  however,  appears  to 
have  no  fixed  relation  either  to  the  intensity  or  extent  of  the 
bellows-sound,  nor  to  the  severity  of  the  disease.  I  have  some- 
times observed  it  very  distinct  in  one  of  the  carotids,  although 
the  bellows-sound  in  it  was  very  feeble  ;  on  the  other  hand,  I 
have  never  met  with  it  in  the  heart,  without  the  other  being  very 
intense. 

In  a  great  number  of  cases  in  which  the  bellows-sound  exists 
in  some  of  the  arteries,  the  pulse  at  the  wrist  has  a  particular 
sort  of  trembling,  exactly  analogous  to  that  of  a  vibrating  cord. 
This  character  of  the  pulse  is  probably  that  observed  by  Corvi- 
sart  in  ossification  of  the  mitral  valves,  when  the  purring-thrill 
exists  in  the  cardiac  region  ;  and  indeed  it  would  seem  to  be 
merely  a  sort  of  diminutive  of  the  latter  phenomenon.  I  have, 
however,  most  frequently  met  with  it  in  cases  in  which  the  bel- 
lows-sound existed  in  some  of  the  arteries,  without  the  purring- 
thrill  ;  but  I  have  met  with  it,  when  this  latter  was  also  present, 
either  in  the  heart  or  arteries.  I  have  sometimes  also  found  it 
when  neither  of  these  phenomena  was  perceived  ;  but  in  this  case 
the  purring-thrill  could  always  be  excited  in  the  brachial  and  cru- 
ral arteries  by  means  of  the  interrupted  pressure  formerly  men- 
tioned, and  in  the  subclavian  and  carotids,  by  making  the  patient 
walk  quickly,  cough,  or  breathe  deeply.  For  these  reasons  I  am 
induced  to  consider  these  three  phenomena,  as  different  modifi- 
cations of  each  other. 

Treatment. — In  augmented  impulse  of  the  arteries,  bleeding 
is  decidedly  indicated,  and  we  fequently  can  only  obtain  relief 
by  having  recourse  to  this  repeatedly  and  extensively.  There 
is  not  so  much  cause  for  this  treatment  when  there  exists  only 
the  bellows-sound  without  increased  impulse.  In  both  cases 
tepid  bathing,  especially  in  the  form  of  the  shower-bath,  is  very 
beneficial.  I  have  also  derived  advantage  from  the  magnet, 
when  the  affection  was  confined  to  the  heart,  but  less  frequently 
than  in  angina.  The  infusion  of  digitalis  and  lauro-cerasus  have 
not  been  found  of  much  benefit.  In  the  simple  bellows-sound 
uncomplicated  with  increased  ynpulsc,  more  particularly  in  pallid 
cachectic  subjects,  steel,  the  fetid  gums,  and  castor,  have  occa- 
sionally proved  useful.  A  moderate  diet  and  abstinence  from 
all  kinds  of  stimulants,  ought,  in  every  case,  to  be  enforced. 


END    OF    THE    TREATISE. 


APPENDIX. 

OF    THE  APPLICATION  OF    AUSCULTATION  TO    OTHER    CASES  BESIDES 
DISEASES    OF  THE    CHEST. 


Sect.  I. — Of  the  Diagnosis  of  Pregnancy. 

It  had  never  occurred  to  me  to  apply  auscultation  to  the  study 
of  the  phenomena  of  gestation.  For  this  happy  idea  we  are 
indebted  to  Dr.  Kergaradec,  who  hit  upon  it  while  verifying 
the  facts  contained  in  the  first  edition  of  this  work.  His  first 
researches  were  made  on  a  woman  very  near  her  confinement. 
He  obtained  two  results,  which  may  now  be  considered  as  the 
most  certain  signs  of  pregnancy.  These  are — 1.  The  pulsation 
of  the  heart  of  the  foetus ;  and  2.  a  sound  denominated  by  its 
discoverer,  simple  blowing  pulsation  (battement  simple  avec 
souffle)  or  placental  sound,  from  a  belief  that  its  site  is  in  the 
placenta  or  in  the  part  of  the  womb  to  which  this  is  attached :  it 
is  evidently  an  arterial  pulsation  accompanied  with  the  bellows- 
sound.* 

The  action  of  the  foetal  heart  is  marked  by  double  pulsations 
like  those  of  the  adult,  only  much  more  rapid,  being  usually  twice 
as  quick  as  that  of  the  pulse  of  the  mother.  These  pulsations 
are  distinctly  audible  in  the  sixth  month,  and  sometimes  even  a 
little  earlier.  The  place  over  which  they  are  perceptible  varies 
with  the  position  of  the  foetus  :  commonly  it  is  pretty  extensive. 
The  space  of  pulsation  is  frequently  near  a  foot  in  length  and 
three  or  four  inches  in  width ;  but  it  is  always  easy  to  determine 
the  precise  point  of  pulsation,  from  the  increased  or  diminished 
intensity  of  the  sound  as  we  approach  or  recede  from  it.  It  is 
probable  that  the  space  over  which  we  hear  the  sound  is  greater 
in  proportion  as  the  foetus  is  near  the  membranes,  in  other  words, 
as  the  liquor  amnii  is  small  in  quantity.  Sometimes  the  sound 
becomes  inaudible  for  hours,  or  even  whole  days;  perhaps, 
sometimes,  on  account  of  the  temporary  feebleness  of  the  action 
of  the  foetal  heart,  but  still  more  frequently,  in  all  probability, 
owing  to  the  recession  of  the  foetus  from  all  contact  with  the 

*  Memoire  sur  rAusctilfation  appliquee  a  1  etude  de  la  grossesse,  par  M.  Le 
Juweau  de  Kergaradec,  D.M.P.     Paris,  1822. 

97 


770  APPENDIX. 

membranes.  It  is  evident  that,  in  order  to  render  the  sound 
fully  audible,  the  body  of  the  foetus,  the  membranes,  the  uterus, 
and  the  abdominal  parietes  of  the  mother  must  be  in  immediate 
contact.  A  turn  of  intestine  placed  between  the  walls  of  the  ab- 
domen and  the  uterus,  is  sufficient  to  prevent  the  sound  from 
being  heard  ;  and  the  waters  of  the  ovum  being  a  worse  conduc- 
tor than  the  solids,  must  also  be  an  impediment,  when  they  exist 
in  too  great  a  quantity  between  the  membranes  and  foetus. 

This  sign  is  of  a  kind  the  certainty  of  which  cannot  be  doubted, 
and  which  cannot  be  simulated  by  any  thing  else;  for  although 
we  certainly  can  sometimes  hear  the  sound  of  the  mother's  heart, 
on  applying  the  stethoscope  to  the  epigastrium,  the  lateral  parts  of 
the  abdomen  or  loins,  the  extreme  difference  of  frequency  between 
the  pulsations  of  the  mother  and  foetus,  renders  the  mistaking  the 
one  for  the  other  quite  impossible.* 

The  excitement  of  the  mother's  circulation  has  no  effect,  at 
least  not  a  constant  one,  on  the  action  of  the  fcetal  heart.  On 
one  occasion  while  M.  Kergaradec  was  exploring  the  fcetal  heart, 
the  pulsations  of  this  became  suddenly  too  quick  to  be  counted, 
while  the  pulse  of  the  mother  continued  of  the  usual  degree  of 
frequency.  After  a  short  time,  the  foetal  pulse  recovered  its 
usual  frequency,  which  varies  from  one  hundred  and  twenty  to 
one  hundred  and  sixty.  I  had  occasion  to  witness  something 
similar.  All  at  once  the  sound  became  extremely  loud,  almost 
equal  to  that  of  the  heart  of  an  adult,  but  without  any  impulse  or 
change  in  the  frequency  or  rythm.  This  state  lasted  only  a  few 
seconds ;  and  was  not  accompanied  by  any  particular  emption  in 
the  mother. 

The  second  phenomenon  discovered  by  M.  Kergaradec  is  evi- 
dently an  arterial  pulsation,  isochronous  with  the  pulse  of  the 
mother,  and  accompanied  with  the  bellows-sound.  It  is  unat- 
tended by  any  impulse.  The  point  where  it  is  heard,  is  always 
fixed  in  the  same  individual,  but  varies  in  each  person  :  and  the 
abdominal  space  over  which  it  can  be  heard  is  usually  less  than 
in  the  case  of  the  fcetal  sound.  Most  commonly  this  space  is 
only  three  or  four  inches  square ;  but  sometimes  it  is  considerably 
larger. 

M.  Mayor,  of  Geneva,  had  heard  the  pulsation  of  the  unborn  foetus,  previ- 
ously to  M.  Kergaradec,  as  appears  from  the  following  note  in  the  Bibtiotluque 
Universelle  for  November,  1S18,  Geneva.  "  At.  Mayor  has  discovered  that  we 
can  ascertain  with  certainty  if  the  foetus  has  nearly  arrived  cat  its  full  time,  or  if 
it  is  living  or  dead,  by  applying  the  ear  to  the  abdomen  of  the  mother  ;  if  the 
child  is  alive,  we  can  hear  distinctly  the  pulsations  of  its  heart,  and  can  readily 
distinguish  them  from  those  of  the  mother."  (This  note  is  by  the  Editor,  in 
the  notice  given  of  the  Report  <5f  M.  Percy  on  "Mediate  Auscultation.")  It 
does  not  appear  that  M.  Mayor  has  prosecuted  his  researches  further,  since  noth- 
ing has  appeared  from  him  since  the  publication  of  M.  Kcrgaradee.— Author. 


DIAGNOSIS    OF    PREGNANCY. 


These  pulsations  have  presented  to  me  nearly  all  the  varieties 
of  the  bellows-sound.  It  usually  becomes  perceptible  about  the 
fourth  month.  As  soon  as  the  uterus  has  risen  above  the  pelvis, 
and  can  be  brought  in  contact  with  the  walls  of  the  abdomen  by 
pressure  on  them  with  the  stethoscope,  we  hear  the  sound  very 
distinctly — perhaps  even  better  than  at  the  end  of  the  period  of 
gestation.  At  the  earlier  period  the  sound  is  somewhat  peculiar. 
It  seems  as  if  a  blast  from  the  bellows  were  discharged  into  an 
empty  bottle.  Later  in  pregnancy,  the  bellows-sound  is  almost 
always  dull,  much  diffused,  and  conveying  no  impression  of  being 
limited  to  the  calibre  of  an  artery.  From  the  observations  of 
Dr.  Kergaradec  and  others,  the  sound  would  appear  to  originate 
from  the  point  of  insertion  of  the  placenta.  It  is  highly  impor- 
tant, in  a  practical  point  of  view,  that  this  fact  should  be  fully 
verified.  The  bellows-sound  is  usually  heard  on  the  side  oppo- 
site to  that  in  which  the  foetal  pulsation  is  perceived  ;  but  this  is 
by  no  means  constant. 

I  am  of  opinion  that  the  sound  in  question  does  not  originate 
in  the  placenta  itself.  The  only  arteries  in  which  it  can  be  sup- 
posed to  be  produced  are  the  hypogastric,  iliac,  and  uterine.  If 
the  two  first  were  the  site  of  it,  we  ought  to  hear  it  on  both  sides 
of  the  uterus  at  once,  or  alternately  in  the  same  individual,  which 
is  not  the "case.  If  all  the  uterine  arteries  yielded  it,  we  ought  to 
hear  it  in  different  points,  and  in  several  at  the  same  time.  What 
seems  to  me  most  probable  is,  that  it  exists  in  the  chief  artery 
distributed  to  the  placenta.  The  following  statement  was  com- 
municated to  me  by  Dr.  Ollivry,  an  experienced  accoucheur,  to 
whom  I  had  sent  an  account  of  Dr.  Kergaradec's  dicovery.  "  I 
have  proved  on  four  women  the  accuracy  of  the  observations 
you  communicated  to  me.  And  I  have  further  ascertained, 
by  the  introduction  of  the  hand  into  the  uterus,  immediately 
after  parturition,  that  the  point  where  I  had  previously  heard 
the  blowing  pulsations,  corresponded  exactly  with  the  point  in 
which  the  placenta  was  implanted.  I  am  so  satisfied  of  the  truth 
of  this  observation,  that  I  do  not  intend  to  repeat  the  experiment, 
which,  by  the  way,  is  rather  painful  to  the  patient.  If  a  fresh 
proof  were  wanting  that  the  cause  is  what  you  have  stated,  it  is 
found  in  the  fact,  that  the  sound  ceases  the  very  moment  the 
umbilical  cord  is  cut:'  I  agree  with  Dr.  Ollivry  in  considering 
this  last  fact  as  quite  conclusive  ;  and  even  if  it  should  happen 
that  we  are  not  able  hereafter  to  determine  more  positively  the 
precise  seat  of  this  variety  of  the  bellows-sound,  it  is  at  least 
certain  that  it  originates  in  the  place  to  which  the  placenta  is 
attached,  and  that  it  is  connected  with  the  action  of  its  vessels  : 
it  will  still,  therefore,  be  justly  named  the  placental  sound.  This, 
sound  is  not  constant ;  it  being  at  times  scarcely  perceptible  fox 


772  APPENDIX. 

days  together.  No  d6ubt  the  interposition  of  a  portion  of  intes- 
tine between  the  arteries  and  the  abdominal  parietes  may  some- 
times render  the  sound  imperceptible ;  but  we  often  hear  it  cease 
and  return  again  while  the  instrument  remains  fixed  in  the  same 
spot. 

In  the  case  of  two  or  more  foetuses,  it  is  evident  that  we  shall 
hear  an  equal  number  of  festal  hearts.  After  the  birth  of  one 
foetus,  we  can,  by  the  same  means,  ascertain  if  there  is  one  be- 
hind. Since  the  publication  of  Dr.  Kergaradec's  memoir,  I  know 
an  instance  in  which  the  existence  of  two  foetuses  was  ascertained 
some  days  before  parturition. 

Besides  the  advantage  of  being  able  to  ascertain  the  attach- 
ment of  the  placenta,  it  is  very  probable,  as  M.  Kergaradec  has 
remarked,  that  auscultation  may  enable  us  to  form  some  judg- 
ment of  the  position  of  the  foetus  previously  to  the  dilatation  of 
the  os  uteri.  This  judgment  will  be  founded  on  the  fact  that  ow- 
ing to  the  bent  position  of  the  foetus  in  utero,  the  sound  of  the 
heart  must  be  much  more  distinct  over  the  back  than  over  any 
other  part  that  comes  in  contact  with  the  uterine  walls.  It  may 
also  be  expected  that  some  light  may  be  thrown  by  this  means  on 
cases  of  extra-uterine  conception  :  but  I  know  of  no  fact  in  sup- 
port of  this  opinion. 

The  study  of  the  phenomena  we  have  been  discussing*  demands 
infinitely  more  attention  than  that  of  those  which  indicate  disease 
within  the  chest.  The  sounds  being  very  feeble,  the  utmost 
silence  is  necessary  during  the  time  of  observation,  and  the 
utmost  care  must  be  taken  to  discriminate  the  sounds  in  question 
from  several  others,  which  are  likely  to  exist  at  the  same  time, — 
for  instance,  the  sound  of  the  mother's  heart, — the  sound  of  the 
intestinal  contents,  and  the  sound  of  muscular  contraction,  pro- 
duced by  the  force  necessarily  used  to  compress  the  abdominal 
parietes  with  the  stethoscope.  It  is  sometimes  requisite  to  bestow 
much  time  on  our  observations,  and  to  repeat  them,  on  account 
of  the  intermittent  character  of  the  phenomena  we  are  investi- 
gating.* 

*  No  one  who  is  aware  of  the  frequent  and  great  difficulties  experienced  by 
practitioners  in  detecting  pregnancy,  and  of  the  vast  importance  of  doing  so  in 
some  cases,  will  have  any  doubt  of  the  great  value  of  the  auscultatory  signs  no- 
ticed in  the  text.  They  are  almost  as  certain  as  the  perception  of  the  fajtal 
movements,  and  more  certain  than  the  touch  ;  and  they  possess  a  very  great  supe- 
riority, in  point  of  convenience  and  delicacy  over  the  latter.  It  is  true,  they 
have  not  been  detected  in  some  cases  of  pregnancy  ;  it  is  probable  that,  owing  to 
some  peculiar  idiosyncracy,  they  may  never  manifest  themselves  in  certain  cases, 
but  ample  experience  proves  that  their  absence  is  a  circumstance  of  extreme  rar- 
ity. Their  absence,  therefore,  must  not  be  considered  as  an  absolute  test  of  the 
non-existence  of  pregnancy  ;  although  their  presence  may  be  looked  upon  as  the 
reverse.  Here,  as  in  every  other  case  in  which  auscultation  is  applied,  we  have 
all  the  other  signs  to  guide  our  judgment  in  the  instances  where  the  foetal  and 
placental  sounds  are  not  detected ;  while  in  the  vast  majority  of  cases,  we  have 


DIAGNOSIS    OF    FRACTURES.  773 


Sect.  II. — Of  the  diagnosis  of  other  diseases  besides  those  of 

the  chest. 

I  had  been  long  of  opinion  that  auscultation  might  be  usefully 
applied  to  different  surgical  cases,  and  particularly  to  the  diagno- 
sis of  urinary  calculi  and  doubtful  fractures  ;  but  I  had  no  leisure 
or  opportunity  of  putting  my  ideas  in  practice.  This  defect, 
however,  has  been  admirably  supplied  by  M.  Lisfranc,  who  has 
lately  published  a  series  of  observations  and  experiments,  which 
leave  no  doubt  on  the  subject,  and  fix,  in  a  precise  manner,  the 
signs  by  which  doubtful  cases  of  the  kind  may  be  recognized.* 
I  shall  here  give  a  brief  account  of  these. 

1.  Fractures. 

The  stethoscope  applied  over  the  place  of  fracture,  on  the 
slightest  motion  of  the  part,  conveys  a  much  more  decided  cre- 
pitous,  than  is  perceived  by  the  naked  ear  during  the  most 
extended  movements  of  the  parts.  In  many  cases,  even  the 
slight  pressure  of  the  ear  on  the  stethoscope  suffices  to  produce 
the  crepitation  ;  a  circumstance  of  no  small  importance,  as  freeing 
the  patient  from  the  pain  necessarily  excited  by  the  motion 
requisite  in  the  manual  examinations.  The  crepitous  yielded  by 
the  more  solid  bones  is  sonorous,  and  resembles  the  sound  pro- 
duced by  breaking  a  piece  of  wood  across  the  knee  ;  it  is  accom- 
panied with  a  sensation  of  roughness  unpleasant  to  the  ear.  The 
sound  yielded  by  the  spongy  bones  is  duller,  and  resembles  the 
effect  of  a  rasp  on  wood  ;  except  that,  now  and  then,  this  noise  is 
broken  by  sounds  of  a  clearer  kind,  like  those  afforded  by  the 
compacter  bones,  only  not  so  loud.  The  crepitous  is  loudest 
over  the  place  of  fracture,  and  gradually  diminishes  as  we  recede 
from  this ;  but  it  may  be  heard  at  a  great  distance  from  the 
fracture,  when  this  is  in  the  compact  part  of  a  long  bone.  In  the 
case  of  fracture  of  the  femur,  the  crepitation  may  be  heard  even 
on  the  skull.     From  this  it  will  appear,  that  the  precise  place  of 

an  additional  sign,  of  almost  infallible  accuracy.  It  cannot,  therefore,  be  denied 
that  this  form  of  physical  diagnosis  has  conferred  even  on  puerperal  medicine  a 
boon  of  immense  value.  For  much  more  complete  and  precise  information  on 
the  subject  of  this  section,  see  Dr.  Ferguson's  Memoir  in  the  Dub.  Med.  Trans. 
vol.    i. '  New  Series,    entitled  "Auscultation    the  only  unequivocal  evidence  of 


Signs  of  Pregnancy,"  in  the  Cyclopaedia  of  Pract.  Med.  vol.  m.—  lransL. 
*  Memoire   sur  de   nouvelles  applications   du  Stethoscope,  par  J.  Lisfranc. 
Now  translated  into  English,  with  notes,  by  Mr.  Alcock.—  Transl. 


774  APPENDIX. 

the  fracture  is  easily  ascertained.  The  sound  from  oblique 
fractures  is  stronger  than  from  those  which  are  transverse  ;  but 
when  one  end  of  the  fractured  bone  rides  the  other,  the  sound  is 
then  obscured,  and  in  some  cases  may  not  be  perceived  without 
slight  extension  or  counter-extension  of  the  limb.  If  the  fracture 
is  comminuted,  the  sensation,  as  of  distinct  portions  of  bone,  is 
conveyed  by  the  stethoscope. 

The  more  that  auscultation  is  applied  to  different  objects,  we 
shall  find  in  general,  that  the  more  is  the  tact  of  the  ear  improved, 
so  that  it  reaches  a  degree  of  delicacy  that  is  quite  surprising. 
We  formerly  saw  that,  in  several  diseases  of  the  chest,  it  conveys 
the  sensation  of  humidity  and  dryness,  of  form  and  extent :  in 
the  case  of  fractures  of  the  bones  of  rabbits,  I  have  been  able  to 
distinguish  whether  the  bones  were  sharp  or  blunt,  or  commi- 
nuted ;  when  the  hand,  on  account  of  the  thickness  of  the  soft 
parts,  could  only  do  so  in  an  obscure  and  doubtful  manner. 
When  fluids  are  effused  around  the  fracture,  a  guggling  is  com- 
bined with  the  crepitation ;  and  which  is  compared  by  M.  Lis- 
franc  to  the  sound  produced  by  a  shoe  full  of  water.  When  the 
fracture  is  compound,  there  is  conjoined  with  the  crepitation,  a 
sound  of  blowing,  something  like  the  sound  of  forced  respiration, 
made  with  the  mouth  open.  It  is  impossible  to  confound  the 
sound  of  fracture  with  that  of  luxation  :  in  the  latter  case,  the 
sound  is  dull  and  obscure,  and  conveys  precisely  the  impression 
of  two  moist  and  polished  surfaces  sliding  over  one  another. 

From  the  preceding  observations  it  results,  that,  by  means  of 
the  stethoscope,  we  may  readily,  and  without  giving  pain,  distin- 
guish every  species  of  fracture,  even  those  of  the  most  doubtful 
kind — for  instance  :  those  of  the  neck  and  condyles  of  the  femur, 
— of  the  fibula,  particularly  at  its  lower  end, — of  the  internal 
malleolus, — of  the  rotula,  longitudinal  and  oblique, — of  the 
radius  and  ulna,  when  only  one  of  these  is  fractured, — of  the 
neck  and  condyles  of  the  humerus, — of  the  acromion  process  of 
the  scapula,  of  the  outer  end  of  the  clavicle, — of  the  scapula 
and  ribs, — of  the  vertebrae, — and  finally,  all  fractures  accom- 
panied with  considerable  swelling  of  the  surrounding  soft  parts, 
which  is  especially  the  character  of  those  in  the  vicinity  of  the 
joints.  In  all  these  cases,  the  stethoscope  applied  over  the  frac- 
tured part,  will  convey  the  crepitus,  on  the  slightest  movement 
of  the  part,  or  even,  as  already  stated,  by  the  simple  pressure  of 
the  instrument.  When  from  the  great  thickness  of  the  sur- 
rounding soft  parts  (augmented,  perhaps,  still  further  by  inflam- 
mation) the  sound  is  obscured,  it  becomes  more  perceptible  upon 
applying  the  instrument  on  the  point  of  the  bone  that  lies  nearest 
the  skin,  on  the  principle  of  solid  bodies  being  better  conductors 
of  sound  than  soft  ones ;    thus  in  fracture  of  the   neck  of  the 


DIAGNOSIS    OF    CALCULI.  ^75 

3  apply  the 
the  ilium. 


femur,  we  apply  the  instrument  upon   the  trochanter  or  crest  of 

thfi  ilium. 


2.   Urinary  calculi. 

The  introduction  of  the  catheter  or  sound,  is,  unquestionably, 
^n  excellent  means  of  ascertaining  the  presence  of  calculi  in  the 
bladder ;  nevertheless  the  sensation  produced  by  its  contact  with 
the  stone  is  sometimes  indistinct ;  and  it  has  certainly  happened 
to  the  most  expert  surgeons  to  perform  the  operation,  when  there 
existed  no  stone  to  be  extracted.  This  circumstance  need  never 
again  occur  if  the  stethoscope  is  employed  in  all  doubtful  cases. 
— When  the  stethoscope  is  applied  to  the  os  pubis  or  sacrum 
while  the  catheter  is  introduced,  we  hear  the  sound  occasioned  by 
this  coming  in  contact  with  the  stone,  much  more  distinctly  and 
loudly  than  we  can  do  with  the  naked  ear ;  and,  indeed,  even  in 
the  obscurest  cases,  the  sensation  communicated  will  be  quite  as 
distinct  as  would  be  that  produced  in  the  open  air  by  striking 
the  instrument,  even  much  more  forcibly,  against  a  stone. — When 
the  bladder  contains  no  stone,  after  the  urine  has  nearly  all 
escaped,  we  perceive  a  guggling  sound  like  that  produced  by 
churning  saliva  between  the  teeth  when  the  mouth  is  closed. 
AVhen  the  bladder  is  completely  empty,  the  motion  of  the  catheter 
backwards  and  forwards,  gives  rise  to  a  noise  like  that  of  the 
working  of  a  pump.  It  is  well  known  that  the  celebrated  Desault 
mistook  a  fungous  tumor  of  the  bladder  for  a  calculus.  M.  Lis- 
franc,  in  order  to  ascertain  whether  this  mistake  could  occur  with 
the  stethoscope,  introduced  pieces  of  flesh  into  the  bladder,  and 
found  that  no  other  sound  was  produced  than  arises  when  the 
bladder  is  empty. 

3.  Abscess  of  the  liver. 

In  the  case  of  abscesses  or  hydatid  cysts  in  the  liver,  when 
opened  into  the  stomach  or  intestines,  or  into  the  lungs,  I  conceive 
the  stethoscope  may  tend  to  supply  us  with  diagnostic  marks. 
In  the  two  cases  first  mentioned,  pressure  on  the  right  hypochon- 
dre  will  probably  occasion  a  guggling  sound  from  the  introduction 
of  the  intestinal  gases  into  the  excavation  in  the  liver.  In  the 
latter  cases,  if  the  abscess  communicates  with  the  bronchia,  we 
ought  to  have  the  cavernous  rhonchus,  cough  and  respiration,  per- 
haps even  pectoriloquy,  and  the  metallic  tinkling. 

4.  Diseases  of  the  tympanum  and  Eustachian  lube. 

If  we  apply  the  stethoscope  upon  the  mastoid  process  of  the 
temporal  bone,  while  the  patient  inspires  forcibly  with  the  nostril 


776  APPENDIX. 

of  the  same  side,  (the  other  being  closed  with  the  finger,)  we  per- 
ceive a  blowing  sound  indicating  the  penetration  of  air  into  the 
mastoid  ceUs.  If  there  is  any  moisture  in  the  Eustachian  tube 
or  tympanum,  we  perceive  a  guggling  very  like  that  of  the  mu- 
cous rhonchus,  and  if  the  mucus  happens  to  obstruct  the  tube,  all 
sound  ceases.  From  this  and  other  analogous  facts,  we  may  as- 
certain  the  patency  or  obliteration  of  the  Eustachian  tube,  and 
may  thus  be  enabled  to  determine  more  particularly  the  cases  in 
which  it  is  proper  to  attempt  curing  deafness  by  throwing  injec- 
tions into  this,  or  by  perforating  the  membrane  of  the  tympanum.* 

5.   Use  of  auscultation  in  veterinary  medicine. 

Although  I  think  auscultation  may  be  found  »f  use  in  the  dis- 
eases of  animals,  I  do  not  expect  that  it  will  ever  be  so  in  the 
same  degree  as  in  man.  In  the  first  place,  in  them  we  lose  at 
once  all  the  signs  supplied  by  the  voice.  But  there  are  likewise 
many  other  obstacles  to  the  use  of  the  stethoscope  in  animals.  In 
the  larger  quadrupeds,  such  as  the  horse  or  bullock,  the  explora- 
tion of  the  heart  becomes  extremely  difficult,  on  account  of  the 
inconvenient  posture  necessary  to  attain  it,  and  on  account  of  the 
form  of  the  sternum.  In  the  horse,  and  probably  in  all  herbivo- 
rous animals,  the  respiration  is  very  indistinct,  being  indeed  hard- 
ly audible,  even  when  the  animal  has  just  ceased  running.  I  am, 
however,  of  opinion,  that  in  the  state  of  disease  it  would  be  more 
perceptible  in  the  sound  portions  of  the  lung,  the  action  of  which 
is,  in  such  case,  doubled  or  tripled ;  and  accordingly  I  found,  in 
one  case,  that  it  was  as  easy  to  recognize  peripneumony  in  a  cow, 
as  in  the  human  subject.  I  ought  to  add,  that  my  researches  on 
auscultation  in  the  diseases  of  animals  have  been  very  limited,  but 
I  am  still  of  opinion,  that  it  will  be  found  very  useful  in  such  cases, 
more  especially  when  conjoined  with  percussion.f 

*  The  author  further  suggests  the  probable  utility  of  the  stethoscope  in  I  lie.  in- 
struction of  the  deaf  and  dumb,  liy  applying  one  end  of  it  to  the  trachea  of  the 
speaker,  and  the  other  to  the  ear  of  the  ]>ii|)il  ; — but  surely  this  must  be  fanciful, 
— or  at  least  of  inferior  value  to  other   means. —  Trims!. 

t  Having  completed  (lie  translation  of  M.  Andral's  valuable  notes  to  this 
new  edition  of  Laennee's  Treatise  on  the  Diseases  of  the  Chest,  and  on  Mediate 
Auscultation,  I  will  add  to  the  Appendix,  in  the  form  of  a  note,  a  summary  of 
some  observations  which  I  have  latelj  made  on  Cerebral  Auscultation.  Willi 
this  addition,  the  present  volume  will  contain  a  general  history  of  every 
application  which  has  been  made  of  this  new  means  of  diagnosis. 

In  the  month  of  July,  ls:;-J,  w  hile  investigating  the  symptoms  exhibited  by  a 
child  laboring  under  chrpnic  hydrocephalus,  i  applied  my  ear  over  the  anterior 
fontanelle,  which  was  open  and  pulsating,  ami  heard  a  very  distinct  bruit  de 
soviet  accompanying  each  pulsatory  movement  of  the  fontanelle,  and  synchro- 
nous with  the  pulsations  of  the  heart. 

Having  made  this  discovery  !  commenced  auscultating  the  heads  of  indi- 
viduals of  all  ages,  and  ascertained  I'm,,!  a  series  of  observations  that  certain 
audible  murmurs  are  constantly  being  developed  within,  or  passing  through  the 


NOTE. 


777 


head ;  and  that  the  head,  therefore,  as  well  as  the  chest,  presents  all  the  condi- 
tions necessary  to  render  auscultation  available  in  investigating  its  diseases. 

In  auscultating  the  head,  mediate  or  immediate  auscultation  can  be  practised. 
But  since  the  head  is  spherical,  and  can  be  readily  and  conveniently  approached 
by  the  ear,  and  since  the  ear,  from  its  peculiar  shape  and  flexibility,  may  be 
more  perfectly  applied  to  the  surface  of  the  cranium  than  the  stethoscope  can 
be,  I  prefer  to  employ  immediate  to  mediate  auscultation,  and  consider  it  the 
more  simple  and  the  more  satisfactory  method  of  the  two. 

In  practising  cerebral  auscultation,  the  person  to  be  examined  should  be  in  a 
horizontal  position,  with  his  head  supported  by  a  pillow.  If  it  be  a  child,  the 
examination  can  be  more  satisfactorily  made  while  it  is  asleep  than  when  awake  ; 
for  while  the  child  is  asleep  its  head  can  be  approached  without  danger  of 
causing  it  to  cry  or  to  become  restless. 

The  head  to  be  examined  should  be  covered  by  a  cap,  napkin,  or  some  soft 
covering.  Such  a  protecting  medium  will  prevent  any  noise,  which  without  it 
might  arise  from  the  friction  of  the  hair  against  the  auscultator's  ear  and  head. 

By  attending  to  these  precautions  I  can,  by  applying  my  ear  to  the  heads  of 
healthy  children,  hear  a  sound  which  is  evidently  produced  by  the  air  imping- 
ing against  the  walls  of  the  nasal  cavities  during  the  act  of  respiration.  It 
commences  and  terminates  with  the  respiratory  act.  This  sound  is  peculiar, 
and  is  readily  recognized.  It  is  the  one  which  first  attracts  the  attention,  and 
resembles  in  all  respects,  except  intensity,  the  respiratory  murmur  caused  by 
the  air  passing  through  the  nostrils  when  the  mouth  is  closed,  and  which  is 
then  audible  to  the  person  breathing.  This  sound,  which  I  would  denominate 
the  cephalic  sound  of  respiration,  is  heard  rather  more  distinctly  during  expira- 
tion than  inspiration  ;  and  becomes  somewhat  modified  when  the  membrane  of 
the  nose  is  affected  by  a  cold  or  other  cause. 

A  second  sound  which  strikes  the  ear  is  one  which  seems  to  be  transmitted  from 
a  distance.  It  is  evidently  that  of  the  heart,  and  is  a  soft  mellow  sound,  resem- 
bling that  produced  by  softly  palpating  our  cheeks  when  moderately  distended 
by  air.  It  corresponds  with  the  action  of  the  heart,  and  varies  in  frequency 
and  intensity  as  the  contraction  of  that  organ  varies  in  rapidity  and  power.  It 
may  be  called  the  cephalic  sound  of  the  heart.  The  cephalic  sound  of  respira- 
tion and  the  cephalic  sound  of  the  heart  are  the  only  sounds  which  auscultation 
discovers  in  the  heads  of  healthy  children  when  they  are  asleep  or  at  perfect 
rest.  If,  however,  the  child  should  cry,  or  speak,  or  swallow  whilst  the  ear  is 
applied  upon  its  head,  then  other  sounds  may  be  heard.  When  the  child  cries 
or  speaks,  the  sound  of  its  voice  is  very  distinctly  heard  at  the  surface  of  his 
head,  or  on  whatever  part  of  it  the  ear  may  be  placed.  It  is  generally  sharp 
and  piercing,  and  seems  to  arise  out  of  the  cranium  itself,  so  near  does  it  appear 
to  be  to  the  ear;  and  when  it  is  heard  through  the  stethoscope,  it  seems  as  if  it 
were  vibrating  about  the  mouth,  and  were  to  pass  into  the  canal,  of  the  instru- 
ment. This  sound  I  would  term  the  cephalic  sound  of  the  voice.  It  vane* 
somewhat  in  its  tone  and  apparent  approximation  to  the  ear  at  different  parts  of 
the  head.  At  the  unclosed  fontanelle  it  is  less  sharp  and  somewhat  more  mel- 
low and  diffusive  in  its  character  than  at  any  other  part  of  the  head,  and  seems 
to  be  further  removed  from  the  surface. 

The  other  sound  which  gains  the  attention  attends  the  act  of  deglutition. 
When  a  child  swallows  any  fluid,  a  sound  of  a  compound  character  is  readily 
distinguished  by  applying  the  ear  to  its  head.  This  sound  is  peculiar  and  can- 
not well  be  described.  It  has  a  liquid,  and  a  dull,  massive  tone,  and  is  evidently 
caused  by  the  act  of  deglutition.  I  shall  therefore  denominate  it  the  cephalic 
sound  of  deglutition.  This  last  named  sound  may  be  best  noticed  while  a  child 
is  nursing,— for  then  it  is  not  liable  to  be  obscured  or  masked  by  the  cephalic 
sounds  of  respiration  or  by  any  movements  of  the  head.  c-   c    * 

I  have  described  these  sounds  as  they  are  developed  in  the  heads  of  infants 
previous  to  the  closure  of  the  anterior  fontanelle.  They  become  modified  in 
some  respects  by  the  influence  of  growth,  and  the  density  of  the ,  brain .and  cra- 
nium. This  is  more  strikingly  the  case  with  the  cephalic  sounds  of  the  heart 
In  early  infancy,  and  prior  to  the  period  of  dentition,  the  cephalic  j>°!»\d  °*  the 
heart  is  distinguished  by  a  softness  and  diffusiveness  of  tone  which  it  does  not 
possess  afterwards.  In  youths  and  adults  the  sound  ™]H»f  »C°JC Ber  an/s 
harsher  tone,  and  seems  to  be  more  remote  from  the  ear.     The  cephalic  sounds 

98 


778  NOTE. 

of  the  voice  and   deglutition  arc  not  so   sensibly  affected  by  the  growth  andin- 
creased  density  of  the  cranium  and  its  contents. 

All  the  sounds  which  I  have  now  described  are  most  distinctly  heard  at  the 
summit  of  the  cranium,  although  they  may  be  easily  detected  at  any  portion  of 
its  surface.  They  are  constantly  occurring  in,  or  traversing  the  heads  of,  heal- 
thy individuals,  and  are  evidently  the  results  of  the  functions  to  which  I  have 
referred  them. 

So  long  as  individuals  are  free  from  disease,  these  cerebral  murmurs  remain 
the  same;  but  I  have  found,  from  observation,  that  they  become  modified,  or 
that  one  of  them  at  least  becomes  modified,  by  the  presence  of  certain  diseases 
within  the  cranium,  and  thus  become  symptoms  of  cerebral  affections. 

The  cephalic  sound  of  the  heart  is  the  one  which  I  have  noticed  as  being 
subject  to  modifications.  This  sound  loses  its  distinctive  character  and  passes 
into  a  distinct  bruit  de  soufflet,  which  I  denominate  the  cephalic  bellows-sound, 
by  the  influence  of  different  diseases  of  the  brain  and  its  membranes ;  and  it  is 
possible  and  quite  probable  that  future  observations  will  show  that  the  cephalic 
sounds  of  the  respiration,  voice,  and  deglutition  are  modified  by  the  same  dis- 
eases. 

I  will  briefly  allude  to  the  cases  in  which  this  cephalic  bellows-sound  was 
present,  referring  to  my  article  contained  in  the  American  Journal  of  the  Medi- 
cal Sciences,  (No.  44,  Aug.  1838,)  for  a  more  extended  account  of  them. 

In  the  first  place,  Iwill  state  that  I  have  noticedthe  cephalic  bellows- sound  inthree 
cases  of  chronic  hydrocephalus,  two  of  which  proved  fatal.  The  sound  in  these 
cases  was  coarse,  abrupt,  and  rasp-like,  and  was  synchronous  with  the  arterial 
pulsations. 

Secondly.  This  sound  I  have  noticed  in  cases  of  congestion  of  the  cerebral 
organs,  produced  by  concussions  of  the  brain,  teething  and  hooping-cough.  In 
these  it  was  short,  abrupt,  rather  coarse.  In  two  cases  of  concussion  of  the 
brain,  the  cephalic  bellows-sound  was  noticed  soon  after  the  injury  was  received, 
and  continued  to  be  heard  during  the  existence  of  the  vascular  excitement,  or 
congestion  of  the  cerebral  organs.  It  could  be  heard  at  every  part  of  the  crani- 
um, and  corresponded  with  the  heart's  action.  This  abnormal  cerebral  sound 
often  attends  the  process  of  dentition.  The  following  facts  have  come  under 
my  notice,  which  go  to  prove  the  existence  of  cerebral  congestion,  in  cases  of 
painful  dentition,  and  also  the  valuable  effect  of  dividing  the  gums  for  the  relief 
of  this  congestion. 

The  cephalic  bellows-sound,  except  in  actual  diseases  of  the  head,  cannot  be 
detected  in  children  previous  to  the  commencement  of  dentition,  and  that  it 
ceases  to  be  heard  after  the  teeth  have  pierced  the  gums ;  and  in  cases  where 
there  is  a  long  interval  between  the  successive  appearance  of  two  crops  of  teeth, 
the  bellows-sound,  which  was  developed  during  the  cutting  of  the  first  crop, 
will  sometimes  cease  during  the  interval,  and  occur  again  during  the  severe  ex- 
citement produced  by  the  cutting  of  the  second  crop  of  teeth.  After  the  whole  of 
the  first  set  of  teeth  have  made  their  appearance,  the  sound  dies  away,  and  sel- 
dom occurs  during  the  second  dentition.  In  a  few  instances,  however,  I  have 
noticed  it  in  children  during  the  process  of  the  second  dentition,  but  never  in 
the  adult,  except  in  actual  cerebral  disease. 

I  have  stated  that  the  cephalic  bellows-sound  disappears  occasionally  during 
the  interval  which  occurs  between  the  cutting  of  two  crops  of  teeth.  I  will 
also  remark  that  the  simple  operation  of  lancing  the  gums  has  in  some  instances 
caused  the  bellows-sound  to  cease. 

I  have  also  noticed  the  cephalic  bellows-sound  in  cases  of  cerebral  congestion 
caused  by  hooping-cough.  This  sound  was  heard  at  the  moment  the  paroxysm  of 
cough  ceased,  and  continued  but  for  a  moment,  and  only  while  the  blood-vessels 
of  the  face  and  head  were  crowded  and  congested  by  their  contents.  It  required 
much  cautious  attention  to  detect  the  sound  in  these  cases,  as  the  panting  of  the 
child,  and  his  restlessness,  and  the  increased  sound  of  respiration,  immediately 
succeeding  the  paroxysm,  all  conspire  to  render  the  symptom  sought  for  inaudi- 
ble. From  the  observations  I  have  made,  however,  I  am  inclined  to  believe  that 
the  cephalic  bellows-sound  is  developed  during  every  severe  paroxysm  of  hoop- 
ing-cough, and  that  it  disappears  as  soon  as  the  patient  begins  to  breathe  freely 
again,  and  the  circulation  becomes  unobstructed. 

Thirdly.     /  have  detected  the  cephalic  bellows-sound  in  cases  of  acute  inflam- 


NOTE. 


779 

around  them. 

e  sound 


mation  of  the  brain  and  its  membranes,  with  serous  effusion  into  or  aroui 

In  these,  the  sound  was  loud,  soft,  diffused,  prolonged,  resembling  th~ 

produced  by  the  rubbing  of  two  pieces  of  soft  and  polished  soap-stone  together. 
At  times  it  passed  from  the  intermittent  into  a  continuous  murmur,  and  was 
characterized  by  a  sort  of  singing  or  buzzing,  constituting  the  musical  bellows- 
sound. 

Fourthly.  1  have  observed  the  cephalic  bellows-sound  in  one  case  in  whichsmall 
abscesses  were  found  in  the  brain  and  serum  within  its  membranes,  caused  by  the 
presence  of  a  kernel  of  coffee  in  the  petrous  portion  of  the  temporal  bone, 
which  it  had  partially  destroyed. 

In  this  case  the  sound  was  strongly  marked  and  sometimes  passed  into  a  con- 
tinuous murmur. 

Fifthly.  I  have  detected  the  cephalic  bellows-sound  in  two  cases  of  induration 
of  the  brain,  with  effusion  into  the  ventricles,  and  at  the  base  of  the  organ. 

In  one  of  these  cases  which  was  that  of  an  adult,  the  sound  was  loud,  pro- 
longed and  diffused  ;  and  when  the  patient  held  her  breath  for  a  moment,  the 
sound  passed  into  a  momentary  whizzing  murmur.  During  the  existence  of  the 
sound,  she  complained  of  noises  and  ringing  in  the  ears,  and  observed  that  these 
sounds  at  times  were  highly  musical  and  harmonious. 

In  the  other  case,  which  was  that  of  a  child,  the  cephalic  bellows-sound  was 
rather  abrupt  and  rasp-like,  and  was  at  no  time  continuous  or  musical  The 
brain  in  this  instance  was  found  on  autopsic  examination  to  be  exceedingly  farm 
and  indurated,  but  no  unusual  amount  of  serum  was  found  deposited  within  or 

"inaH  these  cases  the  cephalic  bellows-sound  was  most  audible  when  the  ear 
was  placed  over  the  unclosed  fontanelle  or  the  summit  of  the  cranium.  It  was 
very  distinct,  however,  at  the  sides,  over  the  temporal  bones,  and  could  be 
heard  in  any  part  of  the  cranium  where  the  ear  or   stethoscope  could  be  ap- 

P  In  searching  for  the  proximate  cause  of  this  new  and  interesting  symptom  in 
the  above  named  cases,  we  are  very  naturally  led  to  locate  it  in  the  arteries 
which  lie  at  the  base  of  the  brain  ;  for  no  organs  are  contained  within  the  cra- 
nium but  the  arteries,  which  can  be  the  seat  of  such  a  phenomenon  Granting 
then  that  the  bellows-sound,  in  the  cases  which  have  been  named,  proceeded 
from  the  arteries  at  the  base  of  the  brain,  its  production  may  be  readily  and 
Sfactorily  accounted  for.  It  is  now  a  well  established  fact  that  the  bellows- 
sound  of  the  heart  and  of  the  arteries  arises  from  an  impediment  to  the  flow  oi 
the  blood  through  these  organs.  An  impediment  to  the  free  passage  of  the 
tlood  through  the  large  arteries  which  lie  on  the  base  of  the  skull  must,  t 
very  evident,  have  existed  in  the  instances  I  have  quoted.  For  the  brain  is 
Sina  strong  and  unyielding  bony  case,  and  is  itself  incompressible 
TaH  the  cases  in  which  the  cephalic  bellows-sound  was  heard,  there  must have 
been  a  pathological  condition  of  the  organs  within  the  cranium  which  w.ou  d 
and  mus?  have  displaced  the  brain  and  forced  it  against  the  compressible  arteries 
on  wSS  Tt  rested.  The  arteries  being  thus  forced  and  pressed  against  the 
bonv  channels  through  which  they  coursed,  their  calibre  must  have  been  di- 
nShS I  at  least  at  certain  points.  This  condition  of  the  arteries  formed  an 
™p  dimen     "he Vee^e  of  blood  through  them,  and   constituted  the 

mmednite  or  proximate  causl  of  the  cephalic   bellows-sound. 

T  thh.  be  thePtrue  rational*  of  this  new  auscultic  symptom,  we  may  expect 
its development  in  every  case  of  cerebral  disease  which  may  cause .any  con- 
sldedreaVble°PFess«re  on  theories  on  ^^^KiSS^X 

stitute  a  commo"PaS7^1SonnlfsIy  that  the  cephalic  bellows-sound  was 
as  my  observations  extend,  I  c; an  on ly  s. y  £     ^^  _     fiut 

a  symptom  of  an  affect. jn^»    one  °p  cages  which  came  underS      notice, 

since  the  sound  ™J°*™*™*™*ndet  different  circumstances  of  the  organs 
and  varied  in  its  tone  andchan «ter  unae  mptom  may  iead  not  only 

tfr^ag^  but  ya,Po  to  a  diagnosis  of  each 

^S2Siiii^^^~{rf  r  rpha,ic  b^—nd-1 

Having  mdue  i  abnormal  cerebral  murmur. 

"  During*  Ty  prac^e  oTc.:rebra.  auscultation,  I  have  noticed  a  modification  of 


780  APPENDIX. 

the  normal  cephalic  sound  of  the  heart  in  six  cases  of  cerebral  apoplexy.  In 
each  of  these  cases  the  sound  of  the  heart,  as  heard  at  the  surface  of  the  crani- 
um, was  decidedly  abnormal.  Instead  of  its  being  soft,  and  appearing  as  if  it  pro- 
ceeded from  a  distance,  as  in  healthy  adults,  it  seemed  to  be  very  near  the  ear, 
and  was  characterized  by  a  kind  of  impulse,  as  if  the  whole  brain  was  suddenly 
raised  up  against  the  calvarium.  So  peculiar  was  this  impulsive  sound  in  some 
of  the  cases,  that  I  could  not  but  believe  that  the  brain  en  masse  did  actually 
strike  against  the  cranium  beneath  my  ear.  The  sound  is  not  easily  described. 
I  compared  it  during  one  or  two  of  my  examinations  to  that  produced  by  tap- 
ping my  cheek  when  powerfully  distended  by  air  with  my  finger  nail,  and  ob- 
served that  I  could  not  separate  the  sound  from  the  idea  of  an  impulse  being 
connected  with  it ;  I  therefore  denominated  it  an  impulsive  sound. 

The  sound,  I  am  aware,  will  not  be  easily  detected  and  recognized  by  one 
who  has  had  no  experience  in  cerebral  auscultation  ;  but  having  made  himself 
familiar  with  the  normal  cephalic  sounds,  and  particularly  with  the  cephalic 
sound  of  the  heart,  the  auscultator  will  meet  with  little  or  no  difficulty  in  distin- 
guishing the  impulsive  sound  under  consideration,  when  he  auscultates  the 
heads  of  those  laboring  under  cerebral  apoplexy.  I  have  heard  it  in  every  case 
of  the  affection  in  which  I  have  practised  cerebral  auscultation,  and  from  this 
fact  I  am  strongly  inclined  to  believe  that  it  is  aconstantsymptom  of  the  disease. 

Indeed,  when  we  consider  the  condition  of  the  brain  and  of  the  arteries  at  its 
base,  which  must  result  from  an  extensive  effusion  of  blood  within  the  cranium, 
we  may  readily  conceive  that  such  a  symptom  would  necessarily  be  developed. 
The  moment  such  an  effusion  occurs,  the  brain  is  suddenly  pressed  down  upon 
the  arteries  on  which  it  rests,  and  also  against  every  point  of  its  bony  case.  It 
cannot  then,  for  want  of  room,  rise  and  fall  with  the  pulsations  of  the  arteries 
at  its  base,  as  it  does  in  its  natural  condition ;  and  this  being  the  case,  the  mass 
of  blood  thrown  from  the  heart  at  each  contraction  of  its  left  ventricle,  would 
strike  with  great  force  against  the  compressed  parts  of  the  arteries,  and  commu- 
nicate a  shock  to  the  brain  which  would  be  transmitted  to,  and  heard  as  an  im- 
pulsive sound  at,  the  surface  of  the  cranium. 

J.  D.  FISHER. 

The  two  following  bibliographical  articles,  having  reference  to  the  whole 
of  the  two  great  subjects  to  which  this  treatise  is  devoted,  are  inserted  together, 
jn  this  place. 

LITERATURE  OF  AUSCULTATION. 

1728.  Lancisi  (G.  M.)  De  motu  cordis,  &c.    Roma.  fol. 

1748.  Brundel  (J.  G.)  De  motu  cordis  Lancisiano.  Goett.  4to. 

1761.  Avenbrugger,  (Leop.  M.  D.)  Inventum  novum  expercussione  thoracis  hu- 
mani  ut  signo  abstrusos  inlerni  pectoris  morbos  detegendi.    Vindob.  8vo. 

1770.  Roziere  (De  la  Chassagne,^f.  D.)  Manuel  des  Pulmoniques,on  traite  com- 
plete des  Maladies  de  la  poitrine  :  il  y  a  joint  une  nouvelle  methode. 
&c.  traduite  du  Latin  d'Avenbrugger.     Paris.  8vo. 

1808.  Corvisart  (J.  N.)  Nouvelle  methode  pour  reconnaitre  les  maladie  sinternes 
de  la  poitrine,  par  Avenbrugger  (Transl.)     Par.  8vo. 

1813.  Dessans,  Essai  sur  la  percussion  de  la  poitrine  (Diss.  Inaug.)     Par. 

1817.  Double  (F.  J.)  Semeiologie  Generale.  (t.  ii.  p.  31.)     Par. 

1819.  Merat.  Diet,  des  Sc.  Med.  (Art  Percussion.)  t  xl.     Par 

1819.  Laennec  (R.  T.  H.)  De  l'Auscultation  mediate.  Ed.  I.  1819.  Ed.  II. 
1826.  Ed.  HI.  par  Mer.  Laennec  3  vols.  Par.  1831.  8vo.  Id.  Trans- 
lated by  Dr.  Forbes.  1st  Ed.  Lond.  1821.  2nd,  1827.  3rd,  1829.  4th, 
1834. 

1821.  Rostan.  Diet,  de  Med.  (Art.  Auscultation)  t.  iii.  Par. 

1822.  Kergaradec  (L.  J.)     Memoire  sur  l'Auscultation  appliquee  a  l'etude  de  la 

grossesse.     Par.  8vo.  , 

1823.  Lisfranc,  (J.)  Memoire  sur  de  nouvelles  applications  du  stethoscope.  Par. 

8vo. 
1823    Hall  (H.  C.  Van)  Diss,  de  stethoscopii  in  morbis  pectoris  usu.   Trag.  ad 
Ren. 

1824.  Forbes,  (John,  M.  D.)  Original  cases  with  dissections,  &c.  and  a  transla- 

tion of  Avenbrugger.     Lond.  8vo 


LITERATURE  OF  AUSCULTATION.  781 

1824.  Collin,  (V.,  M.  D.)  Des  diverses  methodes  d'exploration  de  la  poitrine, 

&c.     Par. 

1825.  Stokes,  (W.,  M  D.)  An  introduc.  to  the  use  of  the  stethoscope.  Ed.  12mo. 

1826.  Scudamore,  (C,  M.  D.)  Obs.  on  Laennec's  method  of  forming  a  diagnosis 

of  diseases  of  the  chest.     Lond-  8vo. 
.   1826.  Andral.  Diet,  de  Med.  (Art.  Percussion.)  t.  xvi.     Par. 
1826.  Hofacker,  (D.,  M.  D.)  Ueber  das  Stethoscop  eintrefflichesmittelzurerken- 
nung  der  krankheiten  des  herzens  und  der  lungen.     Tubing.     ' 

1826.  Gintrac,  (Elie,  M.  D.)  Memoire  sur  le  diagnostic  des  affections  des  or- 

ganes  thoraciques.     Louvain. 

1827.  Graves,  (R.  J.,  M.  D)  Stokes,  (W.,  M.  D.)    A  selection  of  cases  to  prove 

the  utility  of  the  stethoscope.  (Dub.  Hosp.  Reports,  vol.  iv.)  Dubl.  8vo. 
1827.  Stack  (W.,  M.  D)  Report  of  an  inquiry  into  the  value  of  mediate  auscul- 
tation.    (Dub.  Hosp.  Reports,  vol.  iv.)  Dub.  8vo. 

1827.  Alcock  (J.  C.)  A  memoir  on  the  use  of  the  stethoscope  in  fractures,  &c. 

Translated  from  the  French  of  Lisfranc.  Lond.  18mo. 

1828.  Ryland  (W.  N.)  A  short  treatise  on  the  different  methods  of  investigating 

the  diseases  of  the  chest.  (Trans,  of  Collin.)     Lond.  12mo. 

1828.  Piorry,  (P.  A.,  M.  D.  )  De  la  percussion  mediate.  Par.  8vo. 

1828.  Williams  (C.  J.  B.,  M.  D.)  Rational  exposition  of  the  physical  signs  of  dis- 
eases of  the  lungs.  Lond.  8vo. 

1828.  Townsend,  (R.,  M.  D.)  Cases  to  illustrate  the  utility  of  the  stethoscope. 

(Dub.  Trans,  vol.  v.)  Dublin.  8vo. 

1829.  Conwell,  (W.  E.  E.,  M.  D.)  Observations  chiefly  on  pulmonary  diseases 

in  India  and  on  the  use  of  the  stethoscope.  Malacca.  4to. 
1829.  Turner  (J.)  Obs.  on  the  causes  of  the  sounds  of  the  heart.  (Ed.  Med.  Chir. 

Trans,  vol.  hi.)  Edin.  8vo. 
1829.  Andral.  Diet,  de  Med.  et  de  Chir.  (Art.  Auscultation)  t.  iii.  Par. 

1829.  Williams,  (D.,  M.  D.)  On  the  sounds  produced  by  the  action  of  the  heart. 

(Edin.  Journ.  vol.  xxxiii.)  Edin.  8vo. 

1830.  Piorry  (P.  A.,  M.  D.)  Du  procede  operatoire  k  suivre  dans  les  explora- 

tions des  organes.  Par.  8vo. 
1830.  Spittal  (R.)  A  treatise  on  auscultation  Ed.  8vo. 
1830.  Corrigan  (D.  J.,  M.  D.)  On  the  motions  and  sounds  of  the  heart.  (Dub. 

Med.  Trans.  N.  S.  vol.  i.)  Dub.Bwo. 
1830.  Gunther  and  Lau.  Encyc.  Worterbuch.  (Art.  Auscultation)  B.  iv.  Berl 
1830.  Elliotson,  (J.,  M.  D.)  On  the  recent  improvements  in  the  art  of  distin- 
guishing the  various  diseases  of  the  heart.     Lond.  fol. 
1830—1831.  Haycraft,  (W.  T.,  M.  D.)  Illustra.  of  Dr.  Corrigan's  theory  of  the 
motions  and  sounds  of  the  heart.  (Med.  Gaz.  vol.  vii.  &  viii.)  Lond.  8vo. 
1830.  Kennedy  (E.,  M.  D.)  Obs.  on  the  utero-placental  circulation  and  the  pla- 
cental souffle.  (Dub.  Hosp.  Reports,  vol.  v.)  Dub.  8vo. 
1830.  Ferguson,  (J.  C,  M.  D.)  Auscultation  the  only  unequivocal  evidence  of 
pregnancy.  Cases  of  pulmonary  apoplexy  illustrative  of  the  value  of 
auscultation.  (Dub.  Med.  Trans.  N.  S.  vol.  i.)  Dub.  8vo. 
1830.  Hope,  (J.,  M.  D.)  Strictures  on  Dr.  Corrigan's  Essay  on  the  motions  and 
sounds  of  the  heart.  (Med.  Gazette,  vol.  vi.  p.  680) ;  and  Clin,  research- 
es on  the  physiology  of  the  heart's  action  (Ibid.  p.  782.)  Refutation  of 
the  various  objections  to  Dr.  Hope's  theory  of  the  heart.  (Ibid.  vol.  vii. 

E.  390.)  Lond.  1830-1.     Experimental  researches  on  the  action  of  the 
eart.  (Treatise  on  the  dis.  of  the  heart,  p.  10.)  Lond.  1832.  8vo. 
1830    Pieeaux,  New  analysis  of  the  heart's  action  (Journ.  Hebdom.  Avr.)  Par. 
1830.-Id.  (Archiv.  Gen.  de  Med.  Juill,  Nov.  1832.)  Par.  1832. 

1830.  Stokes  (W.,  M.  D.)  and  Hart  (J.)  Obs.  on  the  actions  of  the  heart.  (Edin. 

Journ.  vol.  xxxiv.)  Edin. 

1831.  Bond  (H.  J.  H.,  M.  D.)  Remarks  on  the  second  sound  of  the  heart.  (Med. 

Gazette,  vol.  viii.  p.  11.)  Lond.  12mo. 

1832.  Sharpe  (J.  B.)  Manual  of  percussion  and  auscultation,  from  the  French  of 

Meriad.  Laennec.  Lond.  8vo. 

1832.  Forbes.  Cyclopaed.  of  Pract.  Med.  (Art.  Auscultation,)  Part.  I. 

1832.  Townsend  (R.,  M.  D.)  A  chart  of  auscultation.  Dub.  12mo. 

1832.  Copland,  Diet,  of  Pract.  Med.  (Art.  Auscultation)  Lond.Svo. 

1832.  Rouanet.  On  the  sounds  of  the  heart.  (Journ.  Hebdom.  No.  97.)  Par. 


782  APPENDIX. 

1832.  Haus  (C,  M.  D.)  Die  auscultation  in  bezugauf  Schwangerschaft.  Wurtzb. 

1833.  Kennedy  (E.,  M.  D.)  Observations  on  obstetric  auscultation.  Dub.  8vo. 
1833.  Carlile  (H.)  Exper.  and  obs.  on  the   motions  and   sounds  of  the    heart. 

(Dub  Journ.  of  Med.  Sc.  vol.  iv.)  Dub.  8vo. 

1833.  Fisher  (J.  D.)  Observations  on  the  cephalic  bellows-sound,  (Medical  Mag- 

azine.) Boston. 

1834.  Williams,  Cyclopaedia  of  Pract.  Med.  (Art.  Stethoscope,)  vol.  iv. 

1834    Magendie  (F.)  On  the  mechanism  of  the  sounds  of  the  heart.  (L'Institut. 
Journ.  Gen.  Feb.  1834  ;  Lond.  Med.  Gaz.  June  28,  Sept.  20, 1834.)  Par. 
1838.  Fisher  (J.  D.)  On  cerebral  auscultation.     The  American  Journal  of  Med. 
T>  Sciences.  No.  44.  Aug.  18jfe. 

LITERATURE  OF  DISEASES  OF  THE  CHEST  IN  GENERAL. 

1497.  Montagnana,  (B.)  Consilia,  &c.  (De  segritudinibus  pectoris.)   Ven.  fol. 

1572.  Joubert  (Laur.)  De  affectibus  pilorum,  &c.  De  affectibus  internarum  par- 
tium  thoracis.   Genev.  12mo. 

1588.  Dunus  (Thad.)  De  respiratione  Liber.  Tigur.  8vo. 

1608.  Heurnius  (Jo.)  De  morbis  pectoris  liber.  Antv.  4to. 

1616.  Castellos  (Pet.  Vas.)  Exefcitationes  medicinales  ad  omnes  thoracis  affectus 
Tolos.  4to. 

1628.  Grossius  (Th.)  Lectiones  de  morbis  capitis  et  thoracis,  Ferrar.  4to. 

1664.  Diemerbroeck  (Js.  de)  Disputationum  practicarum  pars  prima  et  secunda 
de  morbis  capitis  et  thoracis.  Utrecht.  12mo. 

1683.  Bellini  (Laur.)  De  urinis  et  pulsibus,  de  morbis  capitis  et  pectoris,  &c. 
Bonon.  4to. 

1688.  Anon.  Traite  de  medicine  sur  les  maladies  de  la  poitrine.  Lion.  12mo. 

1692.  Camerarius  (E.  R.)  Pleuritis  et  abscessus  pectoris.  Tubing.  4to. 

1704.  La  Salle  (J.  P.  de)  Traite  des  maladies  de  la  poitrine.  Bordeaux.  12mo. 

1724.  Blackmore  (Sir  R.,  M.  D.)  A  treatise  on  consumptions  and  other  distem- 
pers belonging  to  the  breast  and  lungs.  Lond.  8vo. 

1739.  Crendel  (M.)  Traite  de  quelques  maladies  de  la  poitrine.  Par.  8vo. 

1740.  Hoadly  (Benj.)  Lectures  on  the  organs  of  respiration.  Lond.  4to. 

1741.  Barbeyrac  (M.,  M.  D.)  Nouvelles  dissertations  sur  les  maladies  de  la  poit- 

rine, du  cceur,  &c.  Amsterdam.  12mo. 

1767.  Bordeu  (Th.  de)  Recherches  sur  le  tissu  muqueux  et  sur  quelques  mala- 
dies de  la  poitrine.  Par.  12mo. 

1770.  Roziere  (De  La  Chassagne,  M.  D.)  Manuel  des  pulmoniques.  Par.  12mo. 

1772.  Ullholm  (J.)  Respiratio  diabetica.  {Linn.  Amcen.  Ac.  VIII.)  Upsal. 

1778.  Hoffman  (C.  L.)  Geschichte  einer  brustkrankheit,  &c.    Munster.  8vo. 

1779.  Orlandi  (P.)  Tractatus  de  morbis  pectoris.  Roma.  4to. 

1784 — 6.  Eschenbach  (C.  G.)  Bemerkungen  ueber  krankheiten  der  brust,  &c.  3 

vol.  Lips.  8vo. 
1788.  Boehme  (C.  G.)  Curmethode  der  wichtigsten  brustkrankheiten.  Leipz.  8vo. 
1793.  Corbella  y  Fondervilla  (Ant.)  Tratado  de  las  enfermedades  agudas  y 

cronicas  del  pecho.  Madr.  8vc 

1801.  Bosch.  (J.  J.  van  den)  Commentatio  exhibens  anatomiam  systematis  respi- 

rationi  inservientis  pathologicam.  Haarl.  4to. 

1802.  Coleman  (E.)  Adiss.  on  natural  suspended  respiration.  Lond.  8vo. 
1814.  Herholdt  (J.  D.)  Ueber  die  lungenkrankheiten.  Numb.  8vo. 

1818.  Grateloup  (F.)  Tableaux  synoptiques,  &c.  des  affections  thoraciques.  Par. 

fol. 

1819.  Anon.  Letters  on  disorders  of  the  chest.  Lond. 

1823.  Lorinser  (C.  J.)  Die  lehre  von  den  lungenkrankheiten.  Berl.  8vo. 

1823.  Mayer  (C.,Jtf.  D.)  Tractatus  de  vulneribus  pectoris  penetrantibus.  Petrop. 

1823.  Westphal  (C.)  Was  hat  man  zu  thun  urn  eine  schwache  brust  zu  starken. 

Quell. 

1824.  Forbes  (J.,  M.  D.)  Original  cases,  illustrating  the  use  of  the  stethoscope, 

&c.  in  diseases  of  the  chest.   Lond.  8vo. 
1824—6.  Andral  (G.)  Clinique  medicale  (torn.  ii.  iii.  Mai.  de  Poit.)  Par.  8vo. 

1828.  Anon.  Die  Brustkrankheiten  ;  oder  guter  rath  und  sichere  huelfe  dagegen, 

&c.  Pest.  8vo.  6  s     ' 

1829.  Mills  (Thos.,  M.  D.)  Of  the  morbid  appearances  in  disorders  of  the  trachea, 

lungs,  and  heart.  Dub.  8vo. 


784  EXPLANATION  OF  THE  PLATES. 

tremities  of  either  half.  d.  A  cap  of  the  same  material  sur- 
rounding and  covering  the  whole  auricular  extremity  of  the 
instrument,  e.  The  central  bore. 
B.  The  stopper  (constructed  to  fit  either  the  upper  or  lower  half 
of  the  instrument)  removed,  a.  Portion  exterior  to  the  fun- 
nelled cavity  when  the  plug  is  in  its  place,  of  the  same  diam- 
eter as  the  stethoscope,  b.  Outer  portion  of  the  plug,  of 
equal  diameter  throughout,     c.  Conical  portion  of  the  plug. 

Fig.  2.  (A.  B.  C.  D.  E.) — Piorry's  Stethoscope  and  Pleximeter. 

This  stethoscope  is  constructed  exactly  on  the  same  principles  as 
that  of  Laennec,  but  with  several  modifications,  intended  to  render 
it  lighter,  smaller,  and  more  portable.  In  it  the  central  bore  and 
conical  cavity  of  the  pectoral  extremity,  are  preserved  of  the  origi- 
nal dimensions,  but  the  body  of  the  instrument  is  greatly  reduced 
in  size,  and  the  proper  width  is  given  to  the  auricular  extremity  by 
screwing  a  thin  ivory  cap  to  the  slender  body  of  the  instrument. 
The  pleximeter  is  attached  to  the  stethoscope  merely  with  a  view  to 
render  the  former  conveniently  portable. 

A.  The  whole  stethoscope  with  the  plug  included,  and  the  plexim- 

eter attached,  as  carried  in  the  pocket. 

a.  The  body  of  the  instrument,  of  one-fourth  the  actual  size. 

b.  Its  auricular  extremity  of  ivory,  and  with  a  screw  for  attach- 

ing it  to  the  auricular  cap  D. 

c.  Its  pectoral  extremity. 

d.  The,  pleximeter,  of  ivory,  screwed  upon  the  body  of  the  steth- 

oscope, and  shutting  in  the  plug  E. 

e.  The  auricular  cap  D.  screwed  upon  the  pleximeter. 

B.  An  additional  portion  of  cylinder  fitted  to  screw  on  A.  at  b.,  for 

the  piifrpose  of  lengthening  the  instrument,  when  one  of  a 
greater  length  is  preferred. 

C.  The  stethoscope  fitted  for  use,  the  pleximeter  being  removed 

and  the  auricular  cap  (D.)  applied.  a.  Auricular  cap 
screwed  upon  the  cylinder,  b.  The  pectoral  extremity  freed 
from  pleximeter  and  cap. 

D.  The  auricular  cap  removed,  interior  view. 

E.  The  plug  or  stopper  removed. 

Fig.  3. — Piomfs  Pleximeter  (connected  with  the  stethoscope. ) 

a.  Internal  screw  for  attaching  it  to  the  end  of  the  stethoscope. 

b.  External  screw,  in  which  the  auricular  cap  is  fixed. 

Fig.  4. — Piomfs  Pleximeter  (not  connected  with  the  Stethoscope.) 

a.  Handles  turned  in  the  ivory. 

This  little  instrument  is  made  of  ivory,  from  an  inch  and  a  half 
to  two  inches  in  diameter,  and  about  one-sixth  of  an  inch  in  thick- 
ness.    It  may  be  made  either  circular  or  ovoid. 

N.B.  All  the  instruments  can  be  accurately  constructed  by  any 
good  turner  from  the  foregoing  descriptions.  The  best  kind  of 
wood  for  the  purpose  is  fine  pencil  cedar.  The  principal  nicety 
consists  in  making  the  bore  perfectly  even  and  smooth.  * 

.f 


/■  nAV 


WF  L158de  1336 

opening:  Title  p^ge 

Exhibited  From  Jan.  £3rd-May  15th  1995 

The  Birth  of    Clinical  Medicine,  Pat  i^  1794-184-8 


-,-  i-'.V.  >-■:,,:  ; 


"v  <$m?.j 


'%,. 


NATIONAL   LIBRARY   OF   MEDICINE 


NLM  DDTfiflbMS  3